Barts Health NHS Trust

3. Miss H complains about the following aspects of the care and treatment the Trust gave her mother Ms S at an outpatient appointment in July 2024 and during her admission from July to September 2024. She says the Trust:

• misled and pressured her mother the week before admission to believe her health was good enough for the operation in July • made mistakes in inserting a stent during the operation in July • did not act as it should when her mother had haemorrhages during her admission • did not monitor her mother’s heart after the operation.

4. Miss H says the failings shortened her mother’s life. This has impacted on Miss H psychologically, emotionally and practically.

5. The outcomes she seeks are an acknowledgement of failings, apologies, service improvements and financial compensation.

6. Ms S had complex medical issues. She had chronic kidney disease, a history of heart failure, raised body mass index (BMI), and peripheral vascular disease (PVD is when blood flow to the legs is reduced due to narrowed or blocked blood vessels).

7. Ms S had poor circulation in her right leg and had had her left leg amputated in the past. Miss H told us how much her mother wanted to save her right leg, and that she had lost several toes a few months previously.

8. The Trust arranged for Ms S to have an angioplasty in July 2024. This is a procedure to widen narrowed or blocked blood vessels. A stent is placed to keep the blood vessels open. The Trust hoped this would improve the circulation to Ms S’s leg and improve its condition.

9. The operation did not go as planned and it was not possible to place the stent. Ms S had some complications and remained in hospital. Her condition deteriorated and she was placed on end of life care in mid-September, and sadly died towards the end of September.

14. Miss H told us her mother attended a ‘fit for surgery’ consultation, which she thought took place in July in the week before her mother was admitted. She told us she felt her mother was pressured into this procedure, which happened so soon after her other surgeries and procedures during that year.

15. The relevant guidance, Consent to treatment, is outlined on the NHS website. It says: ‘Consent to treatment means a person must give permission before they receive any type of medical treatment, test or examination. This must be done on the basis of an explanation by a clinician […] For consent to be valid, it must be voluntary and informed, and the person consenting must have the capacity to make the decision.

The meaning of these terms are: • voluntary – the decision to either consent or not to consent to treatment must be made by the person, and must not be influenced by pressure from medical staff, friends or family • informed – the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead • capacity – the person must be capable of giving consent, which means they understand the information given to them and can use it to make an informed decision’

16. We can see from the records that the Trust properly followed this guidance when filling in the consent form on the day of the operation with Ms S, when it explained the risks of the surgery.

17. We have not seen anything in the records to show there was a consultation on the day in July that Miss H thought. We can see Ms S attended a pre-op assessment in the previous week, where it is documented she attended with her son and was given all the relevant information. Including family support in this decision making was in line with GMC Good Medical Practice which says:

‘You should check patients’ understanding of the information they’ve been given, and do your best to make sure they have the time and support they need to make informed decisions if they are able to.’

18. Our adviser told us that there had been a multidisciplinary team (MDT) meeting to look at whether Ms S should have the procedure. An MDT meeting is where is a group of healthcare professionals from different specialisations work together to provide comprehensive care for patients. This approach ensures that all aspects of a patient's condition are considered, leading to better decision-making and treatment planning. This was in line with Good Medical Practice, which says:

‘7 In providing clinical care you must:

a) adequately assess a patient’s condition(s), taking account of their history, including - symptoms - relevant psychological, spiritual, social, economic, and cultural factors - the patient’s views, needs, and values b) carry out a physical examination where necessary c) promptly provide (or arrange) suitable advice, investigation or treatment where necessary d) propose, provide or 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 will meet their needs e) propose, provide or prescribe effective treatment based on the best available evidence […] g) consult colleagues or seek advice from your supervising clinician, where appropriate h) refer a patient to another suitably qualified practitioner when this serves their needs.’

‘49 To develop and maintain effective teamworking and interpersonal relationships you must:

a) listen to colleagues b) communicate clearly, politely and considerately c) recognise and show respect for colleagues’ skills and contributions d) work collaboratively with colleagues and be willing to lead or follow as the circumstances require.’

‘65. Continuity of care is important for all patients, but especially those who may struggle to navigate their healthcare journey or advocate for themselves. Continuity is particularly important when care is shared between teams, between different members of the same team, or when patients are transferred between care providers.

You must promptly share all relevant information about patients (including any reasonable adjustments and communication support preferences) with others involved in their care, within and across teams, as required.’

19. Our adviser said the minutes of the meeting show the angioplasty procedure and its benefits were properly considered by this MDT, in line with the guidance.

20. We have not seen any evidence in the records of the communication with Ms S and her family to suggest she was misled or otherwise pressured into the procedure.

21. Our adviser gave some more detail about the suitability of the procedure, to set the context for what happened. They explained the MDT minutes show this was the best procedure for Ms S to give her the best outcome, in line with what she was seeking – keeping her other leg. They said she was fit enough for this procedure, as it is done using only a local anaesthetic and is a less invasive procedure than operations that are sometimes used to manage conditions such as hers.

22. The relevant guidance for this procedure is the NICE guidance ‘Peripheral arterial disease’, which says:

‘1.6.1 Ensure that all people with critical limb ischaemia are assessed by a vascular multidisciplinary team before treatment decisions are made.

1.6.2 Offer angioplasty or bypass surgery for treating people with critical limb ischaemia who require revascularisation, taking into account factors including: • comorbidities • pattern of disease • availability of a vein • patient preference’

23. As outlined in paragraphs 18 and 19, Ms S was assessed in line with the relevant guidance. Our adviser said she met the criteria outlined in section 1.6.2, outlined above.

24. We know how concerned Miss H is about whether the Trust made mistakes. Our adviser explained that when this operation is planned the team assesses which stent and size is required. This happened, and the team followed Good Medical Practice when making this assessment, which says clinicians should:

‘d) propose, provide or 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 will meet their needs e) propose, provide or prescribe effective treatment based on the best available evidence’.

25. Unfortunately, when the stent was inserted it took on a shape that was not, and could not have been, anticipated. This meant that Ms S needed a surgical intervention to remedy the issue. The Trust immediately contacted a surgeon to manage the problem and retrieve the stent. This was in line with Good Medical Practice, which says:

‘g) consult colleagues or seek advice from your supervising clinician, where appropriate h) refer a patient to another suitably qualified practitioner when this serves their needs.’

26. Our adviser told us the operation notes showed the repair of the vessel was successfully completed. There was no immediate evidence of any blood leakage. To summarise, the attempt to fit the stent was in line with guidance, and the repair to the artery when it was not possible to fit the stent was also in line with guidance. There is nothing to show any mistakes were made when carrying out the procedure.

27. Miss H told us her mother had haemorrhages when she was an inpatient and the Trust did not take the right action. She said that an ultrasound examination a few days after the operation showed a possible bleed, and this was not acted upon. We understand how worrying this was for the family, especially in light of the need for surgical intervention following the attempt to fit the stent.

28. The Trust carried out a vascular ultrasound study (VUS) a few days after the operation. A VUS focuses on the arteries in the lower limbs. The purpose of this was to assess whether blood flow was as would be expected.

29. There was sufficient information for the purpose of the VUS – it assessed blood flow and found this to be acceptable.

30. The records show there was no active bleeding seen on this VUS. This was reasonable as the there was no suspicion of a bleed and the purpose of the scan was to look at blood flow. Our adviser said it would not be usual to be able to see a bleed using this type of scan.

31. The Trust first identified a haemorrhage when it carried out a CT scan the following week. The CT report noted there was active bleeding. The doctors sought the input of the vascular surgery team, in line with Good Medical Practice which says:

‘g) consult colleagues or seek advice from your supervising clinician, where appropriate h) refer a patient to another suitably qualified practitioner when this serves their needs.’

32. Ms S was taken to the operating theatre promptly the day after the CT scan for a repair of the right femoral artery. The operation notes show the point of bleeding was identified and successfully repaired. Our adviser explained there is no specific guidance that sets out what should happen for this procedure. They said the operation notes show that everything was carried out as it should be.

33. The Trust took a further CT scan on two days later, which confirmed there was no evidence of active bleeding.

34. The Trust had further concerns about a major haemorrhage late in the night in the second week of August, and took immediate action by discussing the matter with the on-call consultant, and making a plan for surgical exploration as soon as a theatre became available.

35. This operation took place in the early morning of the next day. The operation notes show the points of bleeding were identified and successfully repaired.

36. Our adviser explained there is no specific guidance to cover this scenario, where a patient has unexpected bleeding which needs to be identified and corrected. They confirmed that the actions of the Trust were in line with the general guidance outlined in paragraph 18.

37. To summarise, on the occasions when Ms S experienced active bleeding, the Trust acted as it should, in line with the quoted guidance.

38. Miss H told us the Trust did not carry out regular checks of her mother’s heart. We know Ms S had a history of heart problems so we looked to see if her heart was monitored in the way that should be expected.

39. Ms S’s medical history shows she was unwell and had multiple comorbidities, including heart failure. The records show the Trust was aware of this and took this into account when treating her. The heart conditions were a long-standing issue and our adviser told us there is nothing in the records to show Ms S required any immediate or specialised support after her operation. The records show that the treatment took account of her cardiology care.

40. The Trust tried to carry out an electrocardiogram (ECG) to check heart function when Ms S experienced general chest pain in the first week of August, but she refused. An ECG is a test that records the electrical activity of the heart. It helps detect heart problems like abnormal rhythms, heart attacks, or other conditions affecting heart function. The Trust took the correct action by acting in line with Ms S’s wishes, and carried out other tests to rule out the likelihood of heart related issues.

41. The Trust was able to carry out an ECG, with Ms S’s agreement, around two weeks later. Our adviser told us this identified possible heart issues, and the Trust took the correct action by consulting with the team at another trust, who were managing Ms S’s heart condition. The Trust carried out cardiology reviews following this.

42. To summarise, there was nothing to suggest Ms S needed additional heart monitoring after her operation. When the ECG later identified possible heart issues the Trust acted in line with the guidance in paragraph 18 by consulting with the relevant cardiology doctors and carrying out cardiac reviews.

43. We have not found any failings on the part of the Trust in the care and treatment provided to Ms S, or that there was any failure to follow guidance. We were sorry to hear how upsetting this experience was for Miss H. We hope this report explains how we carefully we considered the issues she raised.

1. We have not found any failings in the care and treatment the Trust gave Ms S. For this reason we have not upheld the complaint.

2. We were sorry to hear about the circumstances that led to Miss H bringing this complaint. We understand the experience has caused her and the family much distress. We hope this report provides some resolution to her concerns.