Royal Surrey NHS Foundation Trust

8. Mr Y complains about the care the Practice provided in late 2024 and early 2025. He says the Practice:

• missed opportunities to consider congestive heart failure (CHF) and a leaking mitral valve as a diagnosis • did not identify his abnormal heart sound • did not assess him for swollen ankles • prescribed him an inhaler unsuitable for patients with a heart condition (Symbicort) in January 2025 • prescribed an incorrect urgent prescription dosage in March 2025 and did not respond to requests for clarification.

9. Mr Y also complains about the care Royal Surrey NHS Foundation Trust (the Trust) provided in December 2024. He says the Trust:

• failed to diagnose him with congestive heart failure (CHF) and a leaking mitral valve when he attended hospital in December 2024 • did not properly investigate an abnormality on his chest X-ray results • did not carry out a BNP blood test to exclude CHF • did not call a senior doctor to carry out a flexible nasal endoscopy (FNE) • sent him home with no diagnosis or medication.

10. Mr Y says the missed opportunities to diagnose him could have worsened his condition and put him at increased risk of deterioration. He says he would not have left the UK on a long-haul flight had he been diagnosed with CHF. He says he suffered severe mental trauma, continues to experience flashbacks and struggles to sleep as a result. He says the care he received has also caused distress to his wife and daughter.

11. Mr Y is seeking financial remedy. He is also seeking an apology, an acknowledgement of failings and service improvements.

12. In late November 2024, Mr Y contracted a chest infection while abroad and sought treatment from a doctor. On 20 December 2024, he attended an appointment at his GP practice. His GP prescribed clarithromycin and a salbutamol inhaler for his chest infection.

13. Mr Y attended A&E at the Trust on 26 December and presented with breathing difficulties. The Trust performed several tests, including an ECG, blood tests, flu/covid tests and a chest X-ray. It discharged him that day.

14. On 8 January 2025, Mr Y attended an appointment at the Practice. A GP diagnosed him with asthma and prescribed a different inhaler (Symbicort). In the following days he underwent a breath test, peak flow test and spirometry. He underwent a peak flow test with the doctor and was also prescribed a peak flow meter and diary to complete. On 17 January 2025 he had a followup appointment with a GP at the Practice.

15. On 6 February 2025, Mr Y left the UK. He continued to struggle with shortness of breath and difficulty sleeping. He contacted the Practice who advised it was unable to suggest a replacement inhaler without a physical assessment. It advised him to try stopping his inhaler and suggested he seek advice from a doctor abroad.

16. On 18 February 2025, Mr Y attended a hospital abroad which diagnosed him with congestive heart failure and a leaking mitral valve. He underwent further tests and received treatment to enable him to return the UK. Mr Y arrived back in the UK on 9 March 2025.

17. On 10 March 2025, Mr Y had an appointment with a GP at the Practice and received further prescriptions. The GP referred him urgently for investigations at hospital.

18. On 18 March 2025, Mr Y was diagnosed with congestive heart failure and a leaking mitral valve at the hospital. He was referred to a specialist unit and underwent surgery on 28 March 2025.

The Practice

The Practice missed opportunities to consider congestive heart failure (CHF) and a leaking mitral valve as a diagnosis

22. Mr Y attended a GP appointment on 20 December 2024, with symptoms of a cough lasting a month, blood-stained phlegm and trouble sleeping and breathing. The doctor examined his chest and noted reduced air entry in the lower part of Mr Y’s right lung. The doctor did not identify any crackling or wheezing sounds and took Mr Y’s oxygen level and temperature.

23. The doctor diagnosed a respiratory tract infection and prescribed clarithromycin (an antibiotic) and salbutamol (an inhaler to help open the airways).

24. On 26 December, Mr Y was seen in the Trust ED. He had a chest X-ray and an electrocardiogram/ECG (a test which records the electrical signals produced by the heart), both of which were reported as normal. In the Practice’s final response, it said this X-ray report did not automatically come through to its system, as it did not order it. It said its GPs did not have sight of the actual X-ray images and accepted the judgement of the ED discharge summary and normal X-ray report.

25. At a further appointment on 8 January 2025, Mr Y reported choking and wheezing at night and being woken after two hours. He underwent Fractional Exhaled Nitric Oxide (FeNO) testing, which measures inflammation in the lungs. The GP interpreted the results as symptomatic of asthma.

26. On 13 January, Mr Y had a lung function test (spirometry). A Practice nurse noted the result was suggestive of asthma. The Practice took a blood sample which was reported as normal the following day.

27. On 17 January, the Practice documented Mr Y’s heart rate and oxygen level, and a lung examination.

28. NICE CKS guidelines on heart failure say typical symptoms include breathlessness, nocturnal cough and waking from sleep.

29. Our adviser said Mr Y presented to the Practice several times in December 2024 and January 2025 with shortness of breath on minimal exertion. They said Mr Y had several symptoms suggestive of heart failure, as per NICE guidelines. They said while an initial diagnosis of a respiratory infection was reasonable, the persistence of Mr Y’s symptoms should have triggered consideration of broader differential diagnoses.

30. The FeNO test carried out on 8 January 2025 returned a result of 33 ppb (parts per billion). Our adviser described this as a borderline or intermediate result. NICE CKS guidance on asthma says a clear positive result for asthma is when the FeNO level is 50 ppb or more.

31. Mr Y’s blood test, taken on 13 January 2025, was recorded as normal the following day. NICE CKS asthma guidelines recommend diagnosing asthma if the eosinophil count (a type of white blood cell linked to allergic reactions and inflammation) is higher than the standard laboratory reference range. That was not the case here.

32. Mr Y’s spirometry result of 13 January was documented as showing reversibility of 200 millilitres per second (mLs) FEV1. FEV1 stands for Forced Expiration Volume in the first second, and refers to the maximum volume of air breathed out in one second during a forced breath. The nurse documented this result as suggestive of asthma.

33. NICE CKS asthma guidelines say asthma is indicated when the FEV1 level is 200 mLs or higher and has increased by 12% or more. Our adviser said Mr Y’s result showed an increase of 8.33%, which does not fulfil the asthma diagnostic criterion based on spirometry outlined in NICE CKS Asthma guidance.

34. Based on the above, our adviser said it appeared the Practice had remained focused on a suspected respiratory infection and then on asthma, rather than exploring other differential diagnoses. Given Mr Y’s symptoms, the Practice should have considered heart failure as a potential diagnosis.

35. NICE CKS guidance on chronic heart failure says if chronic heart failure is suspected, clinicians should order an NT-proBNP test. An NT-proBNP test measures a protein in the blood and is typically used to rule out heart failure. Despite Mr Y exhibiting symptoms listed in the NICE CKS heart failure guidance, alongside symptoms atypical of asthma, the Practice did not order an NT-proBNP test. This was not in line with NICE guidance.

36. In summary, Mr Y had several symptoms suggestive of heart failure, as per NICE guidelines. An initial diagnosis of a respiratory infection and further tests to consider asthma were reasonable, but the persistence of Mr Y’s symptoms should have triggered consideration of broader differential diagnoses, including heart failure, particularly as Mr Y’s respiratory test results did not meet the NICE guidance diagnostic threshold for asthma.

37. Our view is the Practice failed to consider differential diagnoses, including potential heart failure, during Mr Y’s appointments in December 2024 and January 2025. This was not in line with the relevant NICE guidance. We consider the Practice missed opportunities to correctly diagnose Mr Y sooner.

The Practice did not identify Mr Y’s abnormal heart sound

38. The records do not show whether the Practice listened to Mr Y’s heart sounds during his appointments.

39. The Practice said it believed the three doctors who saw Mr Y would have identified an audible heart murmur had it been present on examination. It said it believed it had listened to Mr Y’s heart sounds, but acknowledged it had not documented them and apologised for this.

40. GMC ‘Good medical practice’ says clinicians should record their work clearly, accurately and legibly. It says records should include any relevant clinical findings.

41. Our adviser said a patient presenting with shortness of breath alongside other symptoms of heart failure would warrant listening to the heart and documenting any findings. They said the Practice GPs should have documented this information, which it had acknowledged in their final response.

42. We have seen failings in the Practice’s failure to document Mr Y’s heart sounds during his appointments in December 2024 and January 2025. The records show the Practice did not document Mr Y’s heart sounds, although the Practice says it believes it did listen to Mr Y’s heart. We consider the Practice did not act in line with GMC ‘Good medical practice’ guidance during these appointments.

The Practice did not assess Mr Y for swollen ankles

43. The Practice did not assess Mr Y for swollen ankles during his appointments in December 2024 and January 2025. It later explained it did not check his ankles because they were not mentioned as a symptom at these consultations.

44. NICE CKS guidance for chronic heart failure says clinicians should ask patients about typical symptoms of heart failure. These may include fluid retention in the ankles or legs.

45. Our adviser said a patient presenting with undifferentiated shortness of breath alongside other symptoms of heart failure would warrant examining the legs and ankles, or discussing this with the patient and documenting the response.

46. The Practice’s inaction here stems from its failure to consider heart failure as a potential cause of Mr Y’s symptoms, as set out in the earlier section of this report. Our view is that led to the Practice failing to assess Mr Y for swollen ankles during his appointments in line with NICE guidance.

The Practice prescribed Mr Y an inhaler unsuitable for patients with a heart condition (Symbicort) in January 2025

47. The records show Mr Y attended an appointment at the Practice on 20 December 2024 and was prescribed clarithromycin and a salbutamol inhaler for his chest infection.

48. On 8 January 2025, Mr Y attended another appointment at the Practice. The clinical impression was asthma and the GP prescribed a different inhaler (Symbicort).

49. NICE CKS guidance for asthma says clinicians should prescribe initial treatment, such as an inhaler, for newly diagnosed asthma patients.

50. Our adviser said the Practice prescription of an inhaler for Mr Y as initial therapy for presumed asthma was appropriate and in line with guidance. They said while Symbicort can cause cardiac side-effects, untreated asthma also poses risks to cardiac function. They said at this time, heart failure was not part of the GPs working diagnosis.

51. We have not seen any failings on this issue. The Practice prescribed Mr Y a Symbicort inhaler based on its clinical impression, at the time, that Mr Y was suffering from asthma, as recommended by NICE guidance. We have explained above that this was clinically reasonable as an initial working diagnosis even though the Practice should also have considered differential diagnoses.

52. At the time of the prescription, the Practice was not considering heart failure as a potential diagnosis. The Practice prescription of Symbicort was therefore clinically appropriate in isolation and in line with relevant guidance.

The Practice prescribed incorrect urgent prescription dosages in March 2025 and did not respond to requests for clarification

53. Mr Y was prescribed several medications abroad, following his diagnosis with heart failure.

54. On 10 March, Mr Y attended an urgent appointment at the Practice and asked it to renew his prescriptions. The Practice GP prescribed Mr Y enalapril 2.5mg, furosemide 20mg, and lercanidipine 10mg. These are medications used to treat heart failure and lower blood pressure. They explained that one of the medications Mr Y had been prescribed abroad, manidipine, had been changed to lercanidipine because the former was not licensed in the UK.

55. Mr Y contacted the Practice on 11 March seeking clarification on what he considered to be different dosages to those expected. He made a further call on 13 March. There is no record of a response to these queries in the notes.

56. NICE guidelines for chronic heart failure recommend measuring renal function and electrolytes before prescribing ACE inhibitors (medications which lower blood pressure). They specifically list the enalapril dose as 2.5mg twice per day, and note the British National Formulary (BNF) recommends a lower starting dose of once per day.

57. GMC ‘Good medical practice’ says clinicians should work in partnership with patients and respond honestly to their questions.

58. Our adviser said the GP decision to reduce the enalapril dose from the 5mg prescribed abroad to a UK standard starting dose of 2.5mg aligned with NICE and BNF guidance relating to prevention of hypertension and renal impairment.

59. However, the Practice made a mistake in not clearly communicating the clinical reasoning behind the prescription dosages. The Practice did not act in line with GMC guidance on this point.

The Trust

The Trust failed to diagnose Mr Y with congestive heart failure (CHF) and a leaking mitral valve when he attended hospital on 26 December 2024

60. Mr Y presented to the hospital ED with a feeling of choking and breathlessness. He was reviewed by an ED doctor, who documented Mr Y had experienced two to three weeks of worsening difficulty breathing alongside a six-week history of a dry cough. Mr Y received a chest examination which was unremarkable. His chest X-ray and blood test results were also interpreted as normal. Mr Y was subsequently reviewed by an ENT doctor, who attempted a flexible endoscopy, and an acute medical doctor, neither of whom identified any abnormalities.

61. The Trust subsequently discharged Mr Y as no clear cause for his symptoms had been found. He was reviewed by an ENT doctor in February 2025 with no abnormalities identified. Eight weeks later, he was diagnosed with congestive heart failure abroad.

62. NICE guideline NG208 says clinicians should refer a patient for urgent assessment or echocardiography (an ultrasound scan of the heart) if valve disease is suspected based on an identified heart murmur or any relevant medical or family history. It recommends urgent echocardiography if the patient had a systolic murmur (a distinctive ‘swish’ heart sound), exertional syncope (fainting during or after physical exertion), or has severe symptoms of breathlessness thought to be related to heart disease.

63. Our adviser said Mr Y presented with symptoms which focused on his upper airway and throat. They said clinicians who reviewed Mr Y asked about other features such as a cough and wheeze, but these symptoms had seemingly recently improved. They said the clinicians who reviewed him did not identify a pan-systolic murmur, which would have raised a suspicion of mitral valve regurgitation (a symptom of heart failure where the mitral valve fails to close properly), and did not identify pulmonary oedema (a symptom of heart failure where fluid is present in the lungs). They said his ECG was unremarkable and his chest X-ray was interpreted as normal.

64. Our adviser said the clinical impression that Mr Y’s symptoms could be related to an ENT issue was reasonable given his presentation. They said an ENT and acute medical doctor reviewed Mr Y prior to discharge and he was seen in an ENT clinic in February 2025 which reported no abnormalities. They said the systolic murmur and distinctive ‘swish’ sound caused by mitral valve regurgitation is often not consistently present, which can make diagnosis challenging if other clinical signs, such as pulmonary oedema, are not also present.

65. Our adviser said based on Mr Y’s presentation and the results of his investigations, he did not require further urgent assessment for heart valve disease as detailed by NICE guidance.

66. We have not seen any failings on this issue. The Trust reviewed Mr Y in line with NICE guidance when he presented at the ED, performed a clinical examination and ordered several tests. The symptoms identified on Mr Y’s examinations and the results of his investigations did not suggest a requirement for urgent assessment for suspected heart valve disease. We consider the Trust acted in line with relevant guidance on this issue.

The Trust did not properly investigate an abnormality on Mr Y’s chest X-ray results

67. The records show the ED team ordered a chest X-ray for Mr Y when he presented to the hospital ED department on 26 December. The chest X-ray was reviewed by the ED and acute medical teams, both of whom interpreted it as normal. The radiographer who reported on the X-ray documented the lungs appeared slightly congested with slight septal lines. Mr Y was discharged the same day and did not receive any follow-up regarding his chest X-ray.

68. RCEM guidance says the ED team must take responsibility for the checking of reports and acting on any abnormal or missed findings for patients discharged by the ED. It says where a patient is referred to in-patient teams and reports are produced more than four hours later, responsibility for follow-up rests with the in-patient team rather than the requesting ED team. It says the ED team should be mindful of potential circumstances where patient care could be compromised and should be prepared to mitigate against this, rather than exclusively applying the principle that the in-patient team is responsible.

69. The Trust’s internal process for reviewing and endorsing X-ray results says the team that ordered the X-ray would normally be responsible for endorsing the results. It says if a patient is admitted, the admitting team would become responsible for follow-up.

70. The Trust told us that both the ED team and the acute medical team were responsible for endorsing Mr Y’s chest X-ray, because although he had been referred on to the acute medical team from ED and his X-ray had been reviewed by both teams, he was not formally admitted to hospital, which would have formalised the acute medical team’s responsibility for follow-up. They said ultimately, an ED consultant should have reviewed and endorsed Mr Y’s X-ray results, but this did not happen.

71. Our ED adviser said the X-ray findings did not suggest abnormalities meriting admission to hospital and the decision to discharge was clinically reasonable. They said the Trust ED did not act in line with the Trust policy on endorsing the results of Mr Y’s X-ray. They said the Trust acknowledged that the expectations in the ED process is that the X-ray is returned to the specialty who originally ordered it, in this case ED. This would mean the ED consultant should have endorsed the result.

72. Our adviser said there was likely an element of shared responsibility for endorsing the X-ray result between ED and acute medical teams, since both reviewed the X-ray and neither formally admitted Mr Y. They said that a clinician from either team should have endorsed the result, and the fact nobody did means the Trust did not act in line with its internal process or RCEM guidance. They said the Trust should have a clear process for reviewing the results of patients who have been referred on from ED, but whom are not subsequently admitted.

73. Our acute medical adviser said the acute medical team reviewed Mr Y’s X-ray alongside assessing him in-person and interpreted the radiographer’s report alongside this assessment. They said this was in line with standard practice.

74. They said there was a shared responsibility between the ED and acute medical teams to have reviewed Mr Y’s X-ray following his discharge. They said the Trust policy should have ensured someone reviewed and endorsed the radiographer’s report of the X-ray, which did not happen and has been acknowledged by the Trust. The fact Mr Y’s X-ray was not reviewed by a consultant in either specialty was not in line with the Trust’s internal process.

75. We have seen failings in the Trust’s handling of Mr Y’s X-ray report and the fact it did not endorse the results following his attendance at the ED department in December 2024. The records show that both the ED and acute medical teams reviewed Mr Y’s X-ray report and neither endorsed the results following his discharge. Relevant guidance and the Trust’s internal process for the endorsement of X-ray results say that while there is an element of shared responsibility, ultimately it was the ED team’s responsibility to endorse Mr Y’s X-ray results. The Trust has acknowledged this did not happen. We consider this was not in line with guidance.

The Trust did not carry out a BNP blood test to exclude CHF

76. Mr Y presented at the ED with symptoms of breathlessness and a feeling of choking.

77. NICE guidance CG187 1.2.1 says patients with suspected heart failure should be examined and have a history taken by a clinician. It says they should have standard investigations, such as an ECG, blood tests and an X-ray. If, following these investigations, acute heart failure is suspected, NICE guidance recommends a BNP blood test to rule out heart failure (a blood test that measures a hormone produced by the heart).

78. Our adviser said the symptoms Mr Y presented with were not typical of heart failure. They said Mr Y did not show any signs of pulmonary oedema (excess fluid in the lungs) or heart failure in his clinical assessment and his examination results, including an ECG, blood test and chest X-ray, were normal. There was no suggestion that urgent treatment or further intervention was required. They said there was no sign Mr Y had experienced a recent cardiac event as his troponin (a cardiac specific protein in the blood) level was within normal limits in his blood test results. Our adviser said the Trust assessed Mr Y in line with NICE guidance and it was reasonable for it not to have considered a BNP blood test for Mr Y at this stage.

79. We have not seen any failings on this issue. The Trust reviewed Mr Y in line with NICE guidance when he presented at the ED, performed a clinical examination and ordered several tests. These tests returned normal results which did not demand a BNP blood test to rule our heart failure. We consider the Trust therefore acted in line with relevant guidance.

The Trust did not call a senior doctor to carry out a flexible nasal endoscopy (FNE)

80. Mr Y was referred to the ear, nose and throat (ENT) department during his admission on 26 December 2024. He was documented as feeling a choking sensation alongside shortness of breath.

81. The notes show the ENT clinician attempted to carry out a nasal FNE to check Mr Y’s airway but stopped the procedure when they encountered resistance. They also attempted an oral FNE but stopped due to Mr Y experiencing gagging and discomfort. He was discharged with no further ENT input from a senior doctor and was instead booked into an outpatient ENT clinic.

82. On 3 February 2025, Mr Y attended the outpatient clinic and underwent an FNE which showed no abnormal results. He was reassured and discharged.

83. GMC Good medical practice says clinicians should promptly arrange suitable investigations or treatment where necessary and refer a patient to another suitably qualified practitioner when this serves their needs.

84. Our adviser said Mr Y’s referral to ENT was justifiable on the basis of his history of suspected choking in addition to his presenting symptoms. They said an FNE procedure of the nose and upper airway is the accepted standard of examination for any disorder that may affect the upper respiratory tract.

85. Our adviser said the FNE procedure appeared to have been carried out to a satisfactory standard. The procedure was correctly aborted due to inability to pass the endoscope through the nose. The throat was fully examined and no damage was caused by trying to persist with passing the endoscope through the nose.

86. Our adviser explained that endoscopy is an examination procedure that varies in difficulty according to anatomical factors and the experience of the clinician. The skill of endoscopy is not only in passing the endoscope through the nose to the throat but also the interpretation of the clinical findings, including a decision as to what is normal and what is abnormal.

87. They said the decision to arrange for Mr Y to have senior review at a subsequent ENT clinic, which showed a normal upper respiratory tract, was entirely appropriate and in line with GMC guidance and standard clinical practice.

88. We have not seen any failings on this issue. The Trust ENT department carried out appropriate investigations and referred Mr Y to an outpatient clinic for further review when the FNE was unsuccessful. Senior review was not required during his admission. We consider the Trust therefore acted in line with relevant guidance.

The Trust sent Mr Y home with no diagnosis or medication

89. The Trust discharged Mr Y on 26 December 2024 without a formal diagnosis or medication, having undergone an ECG, blood tests, flu/Covid-19 tests and a chest X-ray. The Trust told him he should return if his symptoms worsened.

90. NCEPOD guidance says patients admitted emergency departments should be assessed by clinicians of sufficient experience and authority to implement a management plan.

91. Our adviser said the Trust decision to discharge Mr Y was reasonable. They said the ED, ENT and acute medicine teams all reviewed Mr Y and none felt he needed admission to hospital. They said Mr Y’s reviews by these teams were in line with NCEPOD guidance and had been carried out by competent clinical decision makers, who are qualified to make decisions about admission and discharge.

92. Our adviser said the clinical decision to discharge was justified by the evidence of Mr Y’s medical records and the tests he received. They said his observations were normal, his ECG was normal and the initial view of his X-ray suggesting no abnormalities meriting immediate admission. They said Mr Y was discharged by a competent clinical decision maker, in line with guidance.

93. We have not seen any failings on this issue. The Trust discharged Mr Y from hospital having referred him to three separate teams for review by competent clinicians and several tests, all of which returned normal results. We consider the Trust therefore acted in line with relevant guidance.

Impact – the Practice

94. We have found the Practice did not act in line with NICE guidance when it failed to consider differential diagnoses, including CHF.

95. While treatment in line with guidance from the Practice would not have guaranteed Mr Y a correct diagnosis earlier, our view is that, on the balance of probabilities, it would have made it more likely than not. Had the Practice considered CHF, it would have ordered the relevant blood tests in January 2025. Given that we now know Mr Y was experiencing CHF, we consider blood tests ordered in January would likely have suggested something was wrong and prompted a referral for further investigations. It may have allowed Mr Y to undergo heart surgery at an earlier date. Also, from what My Y told us, a suggestion that something was seriously wrong (for instance from a blood test result), even before a definitive diagnosis, would have meant he would not have travelled abroad in February 2025. As a result, Mr Y would not have suffered much of the distress he experienced when his health continued to deteriorate and he found himself seriously ill abroad.

96. This experience had a significant impact on Mr Y and his family. He told us he feared for his life when he became ill abroad and the experience of feeling so unwell caused him to experience suicidal ideation. He says the experience of being so unwell for several months caused trauma to him, his wife and his daughter, to the extent they continue to experience flashbacks.

97. Mr Y told us when he returned home on 9 March 2025, having received treatment to allow him to fly, he attended an urgent GP appointment the following day and was told to attend hospital the same day. Following an echocardiogram on 18 March, he was told his condition was so serious he should not leave the hospital. Following review by a cardiologist, he was admitted to hospital and told he would need urgent surgery. He told us he feared for his life to the extent he began getting his financial affairs in order and made several transfers to his wife.

98. Mr Y remained in hospital for four days under constant observation before he was moved at 4am via ambulance to a different hospital, where he was told he would imminently receive his surgery. He received his surgery on 28 March. He experienced some atrial fibrillation (a heart rhythm disorder where the heart does not beat steadily) but this was resolved and he was discharged on 1 April.

99. Following his surgery, Mr Y told us his quality of life is significantly improved. He says he is able to sleep consistently where he was previously unable and does not experience symptoms of breathlessness as he did prior to the operation. He says he continues to suffer mental distress as a result of his experience, which he feels may amount to a form of undiagnosed post-traumatic stress disorder (PTSD).

100. We cannot say that all of the distress Mr Y told us about is because of the Practice’s failings. Being diagnosed with a serious heart condition is, in itself, distressing. However, we consider that if Mr Y had received further investigations sooner from the Practice, which could have commenced in January 2024, he would, on the balance of probabilities, not have incurred the same level of distress which he experienced when he became seriously ill abroad. We consider that Mr Y is likely to have made different choices around his travel plans if he had been receiving investigations for heart failure and been referred to a cardiologist by the Practice.

101. We consider the failings of the Practice likely led to avoidable distress for Mr Y which lasted approximately two months. We consider he could have begun further investigations for heart failure in January 2025 and would likely have been diagnosed sooner than he was. We also consider that his experience would likely have been significantly less stressful had he been on an orderly treatment pathway, rather than becoming ill abroad and requiring emergency surgery in March 2025. We have made recommendations for the Practice to put this right at the end of our report.

102. We also considered the impact of the Practice’s failure to communicate the reason for the medication changes. We have not seen any evidence it impacted on Mr Y’s clinical care, although it did cause him worry or distress. The GP’s failure to communicate the clinical reasoning behind his prescription dosages meant that he perceived his prescription as incorrect. The lack of response to his clarification request denied him the opportunity to understand his care plan and may have eroded his trust in the clinician.

103. Our Severity of Injustice (SOI) scale defines a level one injustice as annoyance, frustration, worry or inconvenience typically arising from a single (one-off) incidence, where the effect is of short duration. We conclude a single incident of short duration caused the distress and worry to Mr Y. We recognise it would have been distressing in the context of Mr Y’s recent medical history.

104. Therefore, we consider this complaint component falls at level one on our SOI scale. The Practice acknowledged Mr Y’s concern and apologised for the inconvenience caused. For these reasons, we have decided the apology the Practice has already provided is appropriate remedy for the worry caused by the communication failings.

Impact – the Trust

105. We considered whether the Trust’s failure to properly review Mr Y’s chest X-ray had any impact on him.

106. Our advisers said that because the X-ray showed congestion and slight septal lines in Mr Y’s lungs, it is likely some form of follow up with Mr Y would have been initiated had the X-ray been endorsed by a consultant in line with policy following his discharge. They said this may have taken the form of further tests (such as a repeat X-ray or an echocardiogram) or a review in a suitable clinic.

107. They said this review would not have been urgent and would likely have taken place some weeks later. It is not clear whether this would have affected Mr Y’s travel plans, and it is therefore not possible to say how a follow-up would have affected his ongoing care. While it is possible Mr Y’s CHF could have been identified as a result of the review, given the review would have been non-urgent it is also possible Mr Y would have travelled abroad before any review. It is therefore not possible to say whether a follow up would have changed Mr Y’s clinical progression.

108. We therefore cannot say with any confidence that any follow-up would have happened soon enough to have prevented the distress he later experienced when he became seriously ill abroad. There are too many uncertainties in the potential course of Mr Y’s non-urgent treatment to say that, even if Mr Y’s X-ray results had been endorsed in line with guidance, he would have been seen prior to his travel abroad. Because of this, we cannot say whether the Trust reviewing Mr Y’s in line with guidance would have been likely to change his travel plans and prevented the distress he experienced. Because of this, we are unable to link the identified failing with the claimed injustice. That said, there will be some distress to Mr Y from never knowing whether the correct action could have led to quicker diagnosis and treatment.

1. Based on the evidence we have seen, we consider the Practice missed opportunities to consider differential diagnoses for Mr Y in its treatment of him for asthma. We consider the Practice failed to document Mr Y’s heart sounds and failed to assess Mr Y for swollen ankles during his appointments. We uphold these parts of the complaint.

2. We consider the Practice acted in line with guidance when it prescribed Mr Y a Symbicort inhaler. We consider the Practice made a mistake in not clearly communicating the clinical reasoning behind his changed prescription dosages, but consider the apology Practice has already provided is appropriate remedy for the worry caused. We do not uphold these parts of the complaint.

3. Based on these findings, we recommend the Practice writes to Mr Y to acknowledge the failings identified in Mr Y’s care and treatment and gives a sincere and meaningful apology to recognise the impact this had on him.

4. We also recommend the Practice develops a plan to explain how it will make changes to avoid repeating the failings in the care identified. The Practice should pay Mr Y £1,000 in recognition of the findings made in this report.

5. We consider the Trust treated Mr Y in line with guidance when he attended hospital in December 2024 and appropriately considered CHF as a diagnosis based on Mr Y’s clinical presentation. We consider it followed guidance when ordering investigations, appropriately reviewed in the ear, nose and throat (ENT) department and discharged him from hospital in line with guidance. We do not uphold these parts of the complaint.

6. We consider the Trust did not endorse Mr Y’s X-ray report following his discharge in line with guidance. We partly uphold this part of the complaint.

7. Based on these findings, we recommend the Trust writes to Mr Y to acknowledge and apologise for the failings identified in Mr Y’s care and treatment.

109. We make recommendations in line with our Principles for Remedy, which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

110. Our Principles for Remedy are reflected in our NHS Complaints Standards, which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

111. We have found the Trust did not review and endorse Mr Y’s X-ray results in line with relevant guidance and its internal process following Mr Y’s discharge. While correctly reviewing Mr Y’s X-ray may have resulted in a follow-up appointment being arranged, this would not have been an urgent appointment.

112. We have found the Practice did not act in line with NICE guidance when it failed to consider differential diagnoses, including CHF, for Mr Y. We found the Practice diagnosed Mr Y with asthma based on respiratory test results which did not meet the diagnostic threshold detailed in the NICE guidance. We have found the Practice did not document Mr Y’s heart sounds or assess him for swollen ankles in line with guidance.

113. Considering differential diagnoses as well as asthma, including CHF, documenting heart sounds and assessing for swollen ankles would have made it more likely Mr Y’s heart failure was diagnosed earlier.

114. Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.

115. The Trust should write to Mr Y to:

• acknowledge the failings identified in Mr Y’s care and treatment and give a sincere and meaningful apology to recognise the impact this had on Mr Y. The Trust should send us a copy of this letter within one month of our final report.

116. The Practice should write to Mr Y to:

• acknowledge the failings identified in Mr Y’s care and treatment and give a sincere and meaningful apology to recognise the impact this had on Mr Y. The Practice should send us a copy of this letter within one month of our final report.

117. Our Principles for Remedy say organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred.

118. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. Our Severity of Injustice scale defines a level three injustice as having a moderate impact over a significant period of time. It includes significant distress, which caused a degree of functional impairment, lasting from a few weeks to three months. It also includes cases of minor pain of up to three months and severe pain up to a month. We consider the injustice caused to Mr Y by the Practice’s failings, as described above, sits at level three of our scale.

119. Following this review, we recommend the Practice:

• pay Mr Y £1,000 in recognition of the impact we found. The Practice should pay him this amount within two months of the date of this report, and sends us evidence of the completed payment.

120. Our Principles for Remedy also say organisations should look for continuous improvement and learn lessons from complaints to make sure poor service is not repeated.

We recommend the Practice:

• produces an action plan to address the failings relating to its non-consideration of differential diagnoses, incorrect diagnosis of asthma, non-documentation of heart sounds and non-assessment of swollen ankles • identify the reasons for the failings (where possible) • explain the learning taken and set out what it will do differently in the future (or does differently now) • for each action it should state who is/was responsible, timescale for completion, and how it will be monitored • share the action plan with us, Mr Y, the care Quality Commission (CQC) and NHS England.