Maidstone and Tunbridge Wells NHS Trust

The Practice

3. Mrs R complains the Practice failed to suspect her husband, Mr R, had an aortic dissection (a tear in the main artery) during three encounters on 14 May, 16 May, and 20 May 2024. This means the Practice missed an opportunity to refer her husband for tests which could have diagnosed this condition.

The Trust

4. Mrs R complains that the Trust failed to suspect her husband, Mr R, had an aortic dissection when he attended its emergency department (ED) on 17 May 2024. This means the Trust missed an opportunity to diagnose and treat this condition.

5. Mrs R says her husband died when his aorta ruptured on 22 May 2024 and this could have been avoided. She is devastated by the sudden loss of her husband and her belief that the Trust and Practice could have done more to diagnose and treat his condition has made her bereavement more difficult.

6. Mrs R is seeking service improvements and would like the Practice to apologise for the impact this had on her and her husband.

7. Mr R had a history of chronic lymphocytic leukaemia (CLL), a type of blood cancer which can be managed with treatment. He also had a hiatus hernia, when part of the stomach bulges through the diaphragm.

8. On Monday 13 May 2024 Mr R strained himself and experienced severe pain across his chest, arms, and legs. For the remainder of the day, he suffered from acid reflux and excessive belching. That evening, he called NHS 111 for advice, and it arranged for paramedics to attend him. They contacted the on-call doctor who gave advice for Mr R’s digestive symptoms and planned for another doctor to visit overnight or for Mr R’s GP to phone in the morning.

9. A GP from the Practice phoned Mr R the next day at 8 pm. They prescribed an antacid, a laxative and pain relief.

10. On Thursday Mr R was still unwell with back and stomach pain. He attended a same say appointment with a physician associate (PA) at the Practice. On Friday evening Mr R had severe pain in his stomach, back, and sides, so he went to the ED at the Trust. Blood tests suggested a serious infection, so the Trust gave him antibiotics discharged him.

11. Mr R continued to experience severe pain in his back and sides so on Monday 20 May he saw a GP at the Practice. The GP doubled the dose of pain relief and prescribed a pain relief gel for his knee pain. The GP told him to be alert for symptoms of cauda equina syndrome (a serious condition affecting the nerves in the lower back).

12. In the early hours of Wednesday morning, Mrs R woke up to Mr R making a blowing noise. He was unresponsive so she and her daughter started CPR and called 999. Paramedics arrived quickly, but sadly they were unable to revive him.

13. A postmortem examination found Mr R had died from haemopericardium (blood accumulated in the membrane around the heart) and a ruptured aortic dissection.

The Practice

17. Aortic dissection is a rare condition which affects between three to six people in 100,000 per year in the UK. Sadly, it has a very poor prognosis.

18. GMC guidance section 7 says when doctors provide clinical care they should adequately assess a patient’s condition taking account of their history and symptoms. They should also carry out suitable investigations or examinations and propose treatment based on the best available evidence.

19. We are unaware of any national guidance for suspecting or managing aortic dissection. The AAD guidance explains that aortic dissection presents with sudden onset chest, back, or abdominal pain which is worst in severity at the outset and described as ripping or tearing. This guidance is not aimed at GPs – it is intended for use in South of England hospitals - but it does describe the symptoms which might indicate aortic dissection. GPs do not have access to the tests which diagnose aortic dissection. If they suspect a patient might have aortic dissection they should send the patient to the ED for tests, usually by calling an ambulance.

20. Mr R first felt unwell when he strained himself. He contacted NHS 111 the same day. NHS 111 sent the Practice a report of the outcome of its contact with Mr R. This said: • he had upper abdominal discomfort and excessive burping which he thought might be a recurrence of his hiatus hernia • the paramedic found he had a normal electrocardiogram (ECG), which detects electrical signals from the heart and show heart problems • the on-call doctor suggested he speak to his doctor about a possible referral for endoscopy (an examination of the upper digestive tract using a camera on a thin flexible tube) • the doctor also advised Mr R to stop taking an anti-inflammatory which he regularly took for knee pain, as this might make his symptoms worse.

21. Mr R had three encounters with the Practice after this. Mrs R says this was three opportunities to suspect he had an aortic dissection.

22. On 14 May, Mr R contacted the Practice as he was expecting a call from a GP. He said he was still burping, he had a sore stomach and constipation, and his knee was painful as he had stopped taking his usual pain relief.

23. A GP from the Practice phoned Mr R. The record says he told the GP he had been straining the day before and had acute chest discomfort which went in a few minutes. After this he developed acute acid reflux, burping, and bloating. He had not had any nausea or vomiting, but he had been constipated for around seven days. Mr R reported taking an extra antacid and his indigestion had improved overnight. The GP noted Mr R’s problems as indigestion, constipation and osteoarthritis of his left knee. They prescribed medication to treat these issues.

24. On 16 May Mr R contacted the Practice again. This time he attended and saw the PA. They noted Mr R’s history over the previous few days. Mr R said his acid reflux and constipation symptoms had improved. At this time he had lower back pain on moving and his left groin was aching. He was drinking more and passing urine more frequently. The PA examined Mr R and noted his lower back was not tender and his abdomen was normal. They had no concern about Mr R’s blood oxygen level, pulse rate, or temperature. They suspected musculoskeletal back pain and a new hernia in Mr R’s groin caused by the straining. They took a urine sample to check for a urinary tract infection (UTI) and ordered an ultrasound scan, which creates images of the inside of the body, to see if Mr R did have a new hernia.

25. Mrs R rang the Practice on 20 May and explained her husband had visited the ED over the weekend and needed to see a doctor again. She said he had a bad infection, he still had a nerve pain and he needed more painkillers. Mr R attended the Practice and explained to a GP he had worsening lower back pain which he scored as 12/10 overnight and 3/10 at the time of his visit. The pain radiated into his hips. He said the ED doctors though he had a UTI and chest infection.

26. The GP examined Mr R and found he had a mild spasm in his lower back and had a mild limp. They asked about his constipation and noted this had improved with treatment. They also noted that the results of a urine test which the hospital carried out were available and showed he did not have a UTI.

27. The GP prescribed medication to treat the spasm and advised him how to carry out gentle exercises to help. They thought there was a risk Mr R could develop cauda equina (a serious condition affecting the nerves in the lower back). They told him which warning signs he needed to look out for and told him to come back if his symptoms did not settle.

28. Later that day the GP sent Mr R a back pain survey and he reported that the medication had improved his symptoms.

29. We considered the symptoms Mr R reported. Aside from the brief instance of chest pain which soon improved, taken together our GP adviser explained his symptoms were not typical of aortic dissection, and did not indicate this rare condition. They explained the Practice staff ordered appropriate tests and reached reasonable conclusions based on the symptoms Mr R reported. The proposed treatments were suitable for the problems Mr R appeared to have. We now know Mr R the symptoms may have been caused by a much more serious condition and how difficult this was for Mrs R to learn.

30. The Practice assessed Mr R promptly each time he contacted it. They examined him when they saw him in person. On each occasion the GP or PA considered Mr R’s history and symptoms and reached a reasonable diagnosis based on that. We therefore think the Practice’s actions were all in line with GMC guidance.

The Trust

31. Mrs R complains the Trust did not properly understand her husband’s symptoms when he attended its ED with her on the evening of 17 May and put too much weight on his cough. She said her husband did not report having a cough and just happened to cough when the consultant could hear him. She thought the Trust should have considered the impact of her husband straining more than it did and carried out a CT scan (detailed imaging) of his aorta, which could have diagnosed his aortic dissection.

32. GMC guidance section 7 also applies to the doctors working in the ED.

33. On arrival at the ED the Trust triaged Mr R and recorded that he had experienced lower abdominal pain and he had not opened his bowels for several days. He had no nausea or vomiting and he was passing small amounts of urine. It also noted a past medical history of CLL, hiatus hernia and knee replacement. A nurse carried out observations and took an ECG. Mr R scored his pain as 6/10 but our ED adviser said his observations were otherwise normal.

34. A consultant then reviewed Mr R and noted additional symptoms. Mr R had experienced pain down his arms and legs when he lifted something heavy, discomfort when urinating, pain down the sides of his body, and a new cough. They listened to his chest and heart, which sounded normal. They examined his abdomen and noted some tenderness. They ordered blood tests and a chest X-ray. This is in line with the GMC guidance as they considered history and symptoms, and carried out an examination and tests.

35. Mr R’s blood tests showed raised inflammatory markers, which can indicate an infection, and the X-ray was normal. The consultant suspected Mr R had an infection, either a UTI or a chest infection. They ordered a urine test and prescribed antibiotics. They also prescribed a laxative to help with his constipation and advised Mr R to go back to the ED if his symptoms persisted or if he had further concerns. The urine test results were not available until after Mr R Had gone home. As noted above this suggested he did not have a UTI. This information was not available to the consultant at the time.

36. Our ED adviser said appropriate tests were ordered based on the symptoms Mr R reported. They explained chest X-rays cannot diagnose aortic dissection, but they can show signs which lead to further investigations. If a chest X-ray shows pleural effusion (excess fluid in the space around the lungs), a change in the contour of the aorta, or a globular heart (which appears more rounded), this could indicate aortic dissection and more tests should be considered. A radiographer compared Mr R’s X-ray to one taken a few months earlier and these changes were not present.

37. As Mr R had a history of CLL our ED adviser explained he was sadly vulnerable to infection. A suspicion of an infection was reasonable considering his blood test results. They said the hiatus hernia and constipation also provided one reasonable explanation for Mr R’s abdominal symptoms. As the Trust already had a working diagnosis, it is unlikely they would have suspected aortic dissection.

38. Mrs R recalled her husband told the ED consultant about pain in his chest, as well as his arms and legs, after he strained. She also said the consultant speculated this acute pain may have been caused by the soft gel in his spine being squeezed when he strained. This speculation is not contained within the notes, but the problem Mr R was attending for was abdominal and flank pain. Mrs R also explained her husband never had a knee replacement, even though he needed one, because of the risk of infection. She felt the history of her husband’s symptoms was not properly considered.

39. The note about the knee replacement was not relevant to Mr R’s symptoms and therefore it is unlikely this formed part of the clinical decision making. The ED notes do not mention the pain in Mr R’s chest when he strained. Other than this, the Trust recorded Mr R’s symptoms as Mrs R remembered.

40. Mrs R recalls these events vividly and is confident her husband mentioned chest pain. On the other hand, clinical records are a contemporaneous account of what happened and therefore considered a reliable record. We do not think we can say, even on balance, the Trust failed to record and take account of Mr R’s chest pain when it should have done. We know Mrs R is understandably very distressed this may have been an opportunity to think aortic dissection was the cause of her husband’s symptoms.

41. Based on the evidence we have seen and in line with GMC guidance, the Trust took a reasonable history, carried out appropriate clinical investigations and examinations, and reached a reasonable conclusion based on those factors.

42. Aortic dissection is very rare and sadly difficult to diagnose, in part because it is not always indicated by routine clinical investigations. Prognosis is poor for people with this condition, even when it is discovered in a timely manner. Mr R did not have typical symptoms and the clinical findings from the various tests the Trust and others carried out did not suggest aortic dissection.

43. We are sorry Mr R did not have the opportunity for potentially life saving treatment. Understandably, this has added to Mrs R’s grief. We hope she is reassured by our consideration that this appears to reflect the nature of his condition, rather than because either the Practice or the Trust did anything wrong.

1. We have carefully considered Mrs R’s complaint about the Trust and the Practice. We are sorry to learn her husband, Mr R, died unexpectedly. She is understandably concerned the Trust and the Practice missed opportunities to suspect he had a serious condition, and he could have had a different outcome.

2. We have seen no indication that either the Trust or the Practice did anything wrong during their encounters with Mr R. Mr R sadly died from a rare condition which is difficult to diagnose. We recognise that nothing can change the impact this had. We hope Mrs R takes some measure of reassurance from our consideration.