Lewisham and Greenwich NHS Trust

6. Miss P says the Trust failed to refer her for an invasive angiogram on 19 June 2024. She was also prescribed two medications which were not reviewed.

7. She is increasingly anxious about not knowing what caused her heart failure and how this might progress if there is an undiagnosed underlying cause and she is not monitored or reviewed. She has lost faith in the Trust due to it changing the care plan it agreed on 19 June. She wants the Trust to acknowledge and apologise for delays in investigating the cause of her heart failure.

8. She also says the Trust also gave incorrect information to her GP following two consultations in June 2024. She believes this may result in incorrect care from her GP and it is causing her anxiety. She wants revised information to be shared with her GP.

9. She is seeking an apology for delays in her care, revised information to be shared with her GP, and a referral for an invasive angiogram.

10. Miss P was diagnosed with angina in 2018, which was medication managed. She was advised to take an additional medication following her last angiogram in 2023, but she declined this due to the side effects. She also has diabetes.

11. Miss P started to experience shortness of breath and swelling in her feet from December 2023. She had a fall in January 2024 due to the swelling. It progressively worsened over the following months. She attended A&E on 24 May 2024. Congestive Cardiac Failure (CCF) was suspected and she was prescribed furosemide. The swelling was up to her knees at that time. She was referred to cardiology.

12. Miss P’s cardiology appointment was scheduled for 15 June 2024. She was advised to have an ECG. When the nurse weighed her, she was told she did not need a further ECG if she had evidence of the recent ECG with her.

13. The doctor saw Miss P and told her that all her results are fine, that she could go, and he would write to her GP. Miss P says the consultation took less than five minutes. She says recent progression of heart failure symptoms had an impact on her job. She says there was no history taken from her and no physical examination despite the swelling of her lower legs. The doctor said they saw her blood pressure result and that was normal.

14. Miss P says she asked about her chest X-ray but the results of this were not yet available. Miss P insisted he reviewed the film on PACS, which he did and told her the results appeared normal but said he was not a radiologist. He concluded Miss P did not have heart failure. She asked him to consider her medical history and previous test results and he said these are also normal, without going through them during the appointment itself.

15. She asked about her symptoms of orthopnoea, shortness of breath, and a cough. The doctor said these could be due to sleep apnoea or COPD (chronic obstructive pulmonary disease, a progressive lung disease that affects breathing). Miss P said she does not have a diagnosis of COPD. She says the doctor told her she could go for a second opinion and he asked her to leave. He said that he would write to her GP.

16. Miss P complained to the Trust and was offered an appointment for a second opinion a few days later from a different consultant at the Trust. The consultation for the second opinion was long and thorough, and Miss P asked a lot of questions about her diagnosis of heart failure. She was prescribed two new medications, and the consultant suggested an invasive angiogram with microvascular studies.

17. A respiratory consultant reviewed Miss P two months later and advised it did not believe her heart failure was caused by a lung disease.

18. On 9 July 2024, the consultant wrote a letter to her GP outlining their recommended course of action, which was a stress perfusion cardiac MRI, consideration of invasive microvascular studies, referring to another Trust if assessment indicated this.

19. An MRI was scheduled for 10 October 2024, but Miss P declined this as she wanted to be referred directly to the other Trust for an invasive angiogram.

20. The Trust later contacted her on 26 March 2025 to recommend an MRI with perfusion. Miss P declined this as she was unwell with angina on effort and shortness of breath, and did not feel she would be able to lie down for the duration of an MRI scan. She also had a chest infection at the time and was taking antibiotics. She says she also suffered a severe angina episode during her last MRI with perfusion and was unwell for a couple of days afterwards.

21. She also challenged the previous findings of a perfusion MRI scan being labelled as ‘normal’ when it showed circumferential subendocardial hypoperfusion at mid-ventricular level, and a cardiac MRI being labelled ‘normal’ when the consultant later mentioned it showed evidence of ‘microvascular dysfunction’. She reiterated she wants a referral to another Trust be seen by the consultant cardiologist and professor of interventional cardiology.

22. As she would not accept the MRI scan, the Trust discharged her back to the care of her GP and suggested they refer her to a different Trust for a second opinion if she wished to do so.

26. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong with the Trust’s investigation of heart failure.

27. Miss P says the Trust should have referred her for an invasive angiogram to investigate the cause of heart failure in June 2024. This is a diagnostic test that uses X-rays to visualise the heart’s blood vessels (coronary arteries). It involves threading a catheter through an artery in the leg or arm to the heart, where a special dye in them injected to make the blood vessels visible on X-ray. This helps to diagnose blockages or narrowing of the arteries. Our cardiology adviser explained Miss P’s working diagnosis from the Trust is HFPEF, or heart failure with preserved ejection fraction.

28. HFPEF is a form of heart failure where the pumping action of the heart is preserved but the ventricles are thickened and stiff, preventing adequate filling of the heart with blood. Our cardiology adviser explained it is a challenging diagnosis based on symptoms and signs of heart failure, typical echocardiographic findings, and abnormalities in brain natriuretic peptide (BNP) levels, as per the HFPEF best practice guidance.

29. Miss P had generalised swelling but otherwise did not meet the diagnostic criteria for HFPEF. Our cardiology adviser explained an echocardiogram was reported as showing type 1 diastolic dysfunction (mild dysfunction where the left ventricle relaxes more slowly, resulting in slightly delayed filling on blood to the heart), but the measured parameters did not support a HFPEF diagnosis. They advised such mild dysfunction would not produce the clinical symptoms and physical signs she was experiencing. Her serum BNP level was also reported normal.

30. The Trust’s consultant concluded heart failure was unlikely on 15 June 2024, but Miss P asked for a second opinion. We note that a private consultation in November 2025 also resulted in her being told this diagnosis was not impossible, but unlikely given these results.

However, we understand the diagnosis was assumed based on her clinical symptoms, noting other diagnoses such as her diabetes, which our cardiology adviser says can predispose to HFPEF.

31. The HFPEF guidelines only refer to patients with a confirmed diagnosis, rather than simply displaying some diagnostic criteria. The guidance does not indicate any further investigations for HFPEF would be required in Miss P’s case.

32. We understand that after receiving a second opinion, the Trust told Miss P it would refer her for microvascular studies. Microvascular studies help to diagnose microvascular angina, which was seen as a possible cause for Miss P’s chest pain. It would not help to diagnose or rule out HFPEF.

33. The Trust told Miss P that the consultant at a different Trust responsible for microvascular studies required an MRI with perfusion before the referral could be accepted. MRI (magnetic resonance imagining, a type of non-invasive scan using strong magnetic fields and radio waves to create detailed images). MRI with perfusion is a specialist MRI which looks at blood flow at a microcirculatory level in tissues. As Miss P declined the MRI scan, the referral was not made.

34. Our cardiology adviser explained non-invasive imaging with modalities such as an MRI to demonstrate myocardial ischaemia (reduced blood flow to the heart muscle) and/or microvascular obstruction (when tiny blood vessels to the heart are blocked, reducing blood flow) is in line with the ESC guidelines for the management of chronic coronary symptoms (see fig. 13 from section 5.2.5 which outlines this). The absence of ischaemia or microvascular obstruction on an MRI indicates microvascular angina is highly unlikely, thus avoiding the risk of an invasive procedure. Our cardiology adviser said it was notable that Miss P had had earlier coronary angiograms (a type of X-ray used to check blood vessels) which found normal coronary arteries.

35. We are satisfied the other Trust required an MRI scan with perfusion before it would accept the Trust’s referral, and this was not in the Trust’s control. As Miss P declined the MRI scan, the referral could not be made as it would likely not be accepted.

36. The Trust recommended she speak to her GP for a referral for a second opinion should she wish to explore other options, which is an appropriate alternative. We appreciate Miss P felt unable to accept the MRI at this time due to illness. We are assured that she was given information to make an informed choice about the MRI scan, and she was advised how to seek a second opinion if she wished to do so.

37. As a result, we have not seen signs that anything has gone wrong with the Trust’s investigation of heart failure. As Miss P did not meet the criteria for a HFPEF diagnosis at that time, no further tests were indicated to explore the cause of it. The Trust continued to explore the option of microvascular studies, but as Miss P could not commit to an MRI scan to support the referral, this could not progress. We consider this to be an informed decision. We have therefore decided not to investigate this complaint.

38. We will now consider Miss P’s complaint about the lack of review of prescribed medications.

39. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event(s) complained about had a negative effect which the organisation has not put right. Having done so we have not found any indication that a lack of medication review had a significant negative impact on Miss P. We ordinarily do not investigate issues we consider to have had a low impact or no impact, so we can focus attention on complaints where our work can have the most positive impact on patient care.

40. Miss P complains about the Trust’s lack of medication review following the prescribing of new medications at her second opinion appointment in June 2024; two diuretics called eplerenone and dapagliflozin.

41. Our cardiology adviser explained she was placed on diuretics empirically (meaning based on her symptoms). The diuretics, eplerenone and dapagliflozin, are used in HFPEF but would also be effective in treating other causes of swelling. Our adviser explained it is not unusual for clinicians to try medications to manage symptoms of HFPEF empirically.

42. Dapagliflozin is a diuretic which also helps to manage diabetes. Monitoring of this medication is largely through the monitoring of diabetes, which it is assumed was something Miss P did regularly through home-based blood sugar measurements. Our cardiology adviser explained the diuretic effect of this medication is weak and unlikely to affect kidney function significantly. We note Miss P discontinued this medication, as she mentioned this in a private consultation in November 2025.

43. Eplerenone is also a diuretic which can alter salt levels in the blood, particularly potassium. Our cardiology adviser explained it is usual practice to check renal function and electrolytes between one to two weeks after commencing this medication to ensure no significant rise in potassium level. There is no evidence to suggest the Trust did this, however we accept it may have been tasked to Miss P’s GP.

44. Following the prescribing of this medication, Miss P asked her GP to refer her for a private consultation as she remained concerned about her symptoms. She also had a telephone review on 24 July with the Trust’s consultant who had originally prescribed the medication. In either case, there was no documented discussion about the medication, only that the symptoms had not been alleviated. There are no signs that Miss P raised any concerns specifically about the medication to her GP or to the Trust.

45. Miss P contacted the Trust in August as she received an appointment for an MRI scan when she was not available. She also said she did not believe this was part of the agreed plan. The consultant’s secretary told her she would be reviewed when the consultant returned from annual leave. Correspondence between Miss P and the consultant’s secretary suggest they were on annual leave until mid-August.

46. When the consultant returned, they advised Miss P she needed a cardiac MRI before the referral to the other Trust for microvascular studies and an angiogram. This was scheduled for later in August.

47. Miss P said she was unable to attend due to commitments from late August to mis-September (a period of three weeks) and she also did not believe this was the agreed plan. It was rearranged for October, but she still had reservations, and ultimately it did not take place. The focus of the conversations between Miss P and the Trust during this time was on the MRI scan, and there is no evidence of any concerns about her medication being raised.

48. Whilst we appreciate Miss P was concerned about her presenting symptoms during this time, we were unable to see any evidence to suggest she was specifically concerned about the medication she was prescribed. For example, we cannot see any suggestion that she had any adverse side effects or significant change in her symptoms, or that this prompted her to seek another opinion. Her focus was on accessing an invasive angiogram without the need for an MRI scan first.

49. We think the medication was appropriate as an empirical treatment for her presenting symptoms. There is no evidence of a significant impact relating to the medication or the lack of review, such as unchecked side effects. We are assured she was aware that she could have sought a medication review when pursuing a second opinion through her GP. She did later have a medication review with a private clinician, and no adverse impact was noted. We understand her symptoms have continued, and as such they continue to be under investigation.

50. We appreciate Miss P says the lack of medication review added to her lack of faith in the Trust’s overall care and her anxiety about her condition. As the impact of this appears to be low, we have decided we will not investigate this complaint.

51. Finally, we will consider Miss P’s complaint about the information shared with her GP.

52. Miss P says the Trust also gave incorrect information to her GP following two consultations in June 2024. She believes this may result in incorrect care from her GP and it is causing her anxiety. She wants revised information to be shared with her GP.

53. The Trust says the information provided to her GP is accurate.

54. It specifically says reference to ‘normal’ is due to ‘normal myocardial perfusion reserve’. Myocardial perfusion reserve is the heart muscle’s ability to increase its blood flow in response to demand. As previously mentioned, HFPEF would affect the adequate filling of the heart with blood.

55. Miss P also referred to an early letter dated 13 April 2020 in her complaint, in which it was noted there was a ‘mild change at the subendocardial level in the mid ventricle which could reflect some microvascular ischaemia’ and therefore to her understanding this was not ‘normal’. The Trust explained it used an appropriate synonym to explain this in the letter to GP: ‘suggested possible low volume microvascular dysfunction’. Because of this, the Trust did not believe the letter was inaccurate or needed any amendment.

56. Our cardiology adviser confirmed the Trust’s letters accurately reflect the two different test results referred to in the correspondence with Miss P’s GP. They also advised that microvascular angina is a specialist area of care, so a primary care physician is unlikely to have the knowledge or feel sufficiently confident to recommend specific measures for ongoing treatment. Our cardiology adviser explained the effectiveness of angina medication can be highly variable, so it is largely managed under the guidance of a cardiologist and a GP is unlikely to interfere with the process. These letters are for information only.

57. We appreciate Miss P was anxious to ensure her test results are clearly communicated to her GP to avoid any confusion which could impact on her care. We are assured the information shared with her GP is an accurate reflection of the test results referred to.

58. We understand Miss P’s symptoms are of concern to her whilst investigations are ongoing and the cause remains unclear. We also understand she questions why she is required to take a significant number of medications if she does not have a confirmed diagnosis of a cardiac issue. We are unable to provide medical advice about her medications, and we would encourage Miss P to seek clarity about this from her GP or any other current care providers familiar with her history.

1. We have carefully considered Miss P’s complaint about Lewisham and Greenwich NHS Trust (the Trust).

2. After careful consideration, we have seen no indication that anything went wrong with the Trust’s investigations of heart failure in June 2024. This is because Miss P’s diagnosis of heart failure with preserved ejection fraction (HFPEF) was a clinical diagnosis based on diagnostic criteria but not confirmed. We understand the HFPEF guidelines, which we will explain below, only apply in cases of confirmed HFPEF, so further investigations were not required in Miss P’s case.

3. We have not seen evidence that anything went wrong because of a lack of medication review. This is because we cannot see signs of any obvious impact or any concerns raised by Miss P about any new side effects or symptoms. We also do not know if Miss P’s GP offered a blood test as we do not have access to her GP medical records.

4. Finally, we also have not seen signs that anything went wrong with the information the Trust shared with Miss P’s general practitioner (GP). The information shared was an accurate reflection of her test results. It was also unlikely that any information shared with her GP would have impacted on her care or treatment due to microvascular angina being a specialist area of care which is ordinarily cardiology-led.

5. We will now explain our decision.