The Royal Orthopaedic Hospital NHS Foundation Trust

3. Mr C complains about the Trust specifically relating to the care that his late father, Mr D.

4. Mr C complains the Trust: • deemed his father was ‘fit for surgery’, despite an electrocardiogram (a test that records the electrical activity of the heart, including the rate and rhythm) showing an electrical conduction delay called right bundle branch block and occasional atypical (ventricular ectopic) beats • failed to complete further cardiac tests following the abnormal electrocardiogram (ECG) reading.

5. Mr C states because the Trust failed to pick up on his father’s heart conditions prior to his surgery, he underwent surgery. Mr C says it contributed to his father suffering with a cardiac arrest and heart disease. Mr C says because of the Trust’s failures, his father was deprived an opportunity to have his heart condition treated which may have changed his chances of survival.

6. As an outcome to his complaint, Mr C would like an acknowledgment of the failings, apology, service improvements and a financial remedy.

7. Mr D has a pre-operative assessment for elective total hip surgery replacement at the end of July 2024.

8. Mr D underwent elective total hip replacement surgery in October 2024 and sadly died at the beginning of March 2025.

Fitness for surgery

13. Mr C says his father had history of high cholesterol (too much of a fatty substance called cholesterol in the blood).

14. Mr C also says the Trust classed his father as ASA Grade 2 (scale describing fitness to undergo an anaesthetic), which indicates mild systemic disease. Systemic means affecting the body as a whole or one or more body systems.

15. Mr D’s ECG showed right bundle branch block, an electrical conduction delay in the heart, and occasional ventricular ectopic beats, which are extra heartbeats that start in the lower chambers of the heart. Mr D was also clinically obese and 75 years old.

16. Mr C does not believe his father was fit for surgery. He also considers the Trust did not properly take account of his father’s ECG findings, age, obesity and wider clinical picture before proceeding with surgery.

17. In its complaint response, the Trust says it balanced the risks and the benefits of the elective surgery and it has explained these to Mr D before going ahead.

18. The records show Mr D underwent a formal pre-operative assessment at the end of July 2024. This included a structured medical history, medication and allergy review, assessment of functional capacity, cardiovascular and respiratory assessment, baseline observations, body mass index (BMI) calculation and ASA grading.

19. Mr D also underwent pre-operative blood tests including, full blood count, renal function, and MRSA screening. MRSA stands for meticillin-resistant Staphylococcus aureus, a type of bacteria resistant to many common antibiotics.

20. Mr D also underwent a pre-operative ECG. The pre-operative ECG showed right bundle branch block and frequent ventricular ectopic beats.

21. Records detail the Trust discussed with Mr D all the results of these investigations. Records also detail the Trust discussed with Mr D the risk and benefits of the elective hip surgery. It is recorded Mr D understood the risks and benefits and consented to the surgery.

22. Records also detail the Trust undertook a further preoperative clinical review on the day of the surgery, in October 2024. During this clinical review, the Trust reviewed the relevant history, examination findings, investigations and review the risk.

23. The Trust assessed Mr D as ASA grade 2 (ASA2), which reflected mild systemic disease, including obesity and high cholesterol.

24. To aid our understanding we sort advice from our adviser. They explained Mr D’s ECG findings were abnormal, but this alone did not mean Mr D had a clinically significant cardiac disease or was unfit for surgery.

25. Our adviser explained age and obesity alone would not mandate further cardiac investigations in the absence of symptoms or suspected structural heart disease. Pre-operative assessment is guided by the overall clinical picture, not by ECG findings alone.

26. We recognise Mr C is concerned the Trust did not consider the abnormal ECG findings together with his father’s obesity and age.

27. The American Society of Anaesthesiologists (ASA) Physical Status Classification System has been in use continuously since 1961. The purpose of the system is to assess and communicate a patient’s pre-anaesthesia medical comorbidities. The classification system in conjunction with other factors (e.g., type of surgery, frailty, level of deconditioning) helps anaesthesiologists estimate perioperative risk.

28. The ASA classification details the definition for ASA2 is ‘mild diseases only without substantive functional limitations or end organ involvement. Current smoker, social alcohol drinker, obesity (30<BMI<40), well-controlled high cholesterol, mild lung disease, mild cognitive dysfunction, isolated mild/moderate obstructive sleep apnoea with compliance with continuous positive airway pressure therapy, as prescribed.’

29. Based on the evidence we have seen so far, the ASA classification system and Mr D’s records, we are of the view the Trust’s preoperative assessment is in line with the ASA classification. Notably, Mr D’s body mass index (BMI) was between 30 and 40, which falls within the obesity range, and he had mild diseases without substantive functional limitations.

30. We can see medical records document Mr D’s ECG findings and note Mr D did not report any cardiac symptoms such as chest pain, syncope, exertional breathlessness, concerning palpitations or symptoms of heart failure.

31. NICE NG45 makes recommendations on the routine preoperative tests for people aged over 16 who are having elective surgery. It aims to reduce unnecessary testing by advising which tests to offer people before minor, intermediate and major or complex surgery, taking into account specific comorbidities (cardiovascular, renal and respiratory conditions and diabetes and obesity). This guidance is relevant to this complaint as it provides guidance on what should have happened to assess risk before proceeding or deciding to undertake surgery.

32. NICE NG45 recommends routine pre-operative testing should be guided by the patient’s age, ASA grade, comorbidities and type of surgery.

33. Based on NICE NG45 we can see Mr D had a total joint replacement which would be classed as major or complex surgery.

34. Based on Mr D’s ASA grade and the type of surgery, we can see NICE NG45 recommends full blood count, ECG and kidney function test. Based on medical records we can see Mr D had his medical history taken and an assessment of functional capacity, including kidney function, cardiovascular and respiratory assessment. He had an ECG, baseline observations including blood pressure, pulse, temperature and oxygen levels, a BMI calculation and ASA grading.

35. As such, it is our view, the Trust undertook the tests recommended in NICE NG45 guidance.

36. Royal College of Anaesthetists makes recommendations on the type of function tests needed for a full preoperative assessment, such as cardiovascular and respiratory assessments, similar to NICE NG45 guidance. Based on Mr D’s medical records, we are reassured to see the Trust also undertook the tests recommended by the Royal College of Anaesthetists guidance.

37. Royal Collage of Anaesthetists recommends using a risk stratification in the context of the planned surgery and Revised Cardiac Risk Index (RCRI), which estimates the risk of cardiac complications associated with non-cardiac surgery. Based on medical records Mr D’s score is 0, placing him in a low predicted perioperative cardiac risk group. As such, these tools would have supported the decision to proceed with surgery.

38. Our adviser reviewed Mr D’s ASA grade and preoperative investigations and advised the assessment and baseline testing were appropriately performed and consistent with usual accepted practice.

39. We acknowledge Mr C’s concern about the preoperative assessment. We know that sadly in March 2025, Mr D had a cardiac arrest. We recognise Mr D’s death certificate states ‘underlying heart disease’. As such, we consider it was reasonable for Mr C to try to seek answers to determine if anything could have been done sooner to treat this underlying condition. From our communication with Mr C we can see he cared deeply for his father and his father’s death was unexpected.

40. Based on Mr D’s medical records, the Trust undertook a full preoperative assessment of Mr D’s clinical picture before surgery. The assessment included the grading and investigations recommended by the Royal Collage of Anaesthetists, NICE NG45 and American Society of Anaesthesiologists.

41. In line with the above guidance, the Trust considered Mr D fit for surgery. It explained to Mr D the risks and benefits of surgery. The consent documentation records discussion of procedure-specific risks and general medical and anaesthetic risks, including heart attack, irregular heart rhythms, stroke and death.

42. In summary we consider the Trust’s assessment of fitness for surgery was reasonable, in line with NICE NG45 and wider Royal Collage of Anaesthetists guidance, and consistent with usual anaesthetic practice.

Further cardiac investigation/treatment

43. Mr C says, following the ECG, the Trust did not make any further referrals or proposed any further investigations to monitor and/or treat the cardiac right bundle branch block and frequent ventricular ectopic beats.

44. The medical records do not detail a diagnosed cardiac condition before surgery.

45. The pre-operative assessment identified ECG findings of right bundle branch block and ventricular ectopic beats.

46. Medical records did not document cardiac symptoms such as chest pain, syncope (fainting or passing out), exertional breathlessness, concerning palpitations or symptoms of heart failure. The records document a cardiovascular examination done in July 2024 did not create cause for concern with regards to Mr D having a surgery.

47. The records also document Mr D did not report any cardiac related symptoms in July 2024 or on the day of the surgery in October 2024.

48. Medical records document the operation and immediate postoperative recovery appear to have been uncomplicated. Mr D was discharged home after two days.

49. At a follow-up appointment in January 2025, Mr D reported to be pain free, mobilising independently and pleased with the outcome of the hip surgery.

50. NICE guidance on diagnosis, investigating and treating heart conditions, highlights the importance of reviewing a patient’s symptoms and taking any symptoms into account before making a diagnosis of a heart condition. It also details the importance of tests such as full blood count, liver function test and/or ECG, if patients report cardiac symptoms.

51. We note Mr D did not report any cardiac symptoms, however, we can see from the records the Trust undertook a full blood count and a liver function test as part of the preoperative assessment. Taken together, the available information did not suggest an unstable or undiagnosed cardiac condition that would have required the postponement of surgery or further cardiac investigation.

52. Our clinical adviser explained cardiac complications directly related to surgery or anaesthesia would usually be expected to occur during the perioperative period, in the first few days after surgery or within 30 days of surgery.

53. We are reassured to see that in January 2025, Mr D reported the surgery was beneficial and did not report any cardiac symptoms.

54. We fully appreciate Mr C’s concerns that his father’s death could have been prevented. It is understandable his father’s death was a very upsetting for Mr C and his family. We understand how distressing this time was and remains for them.

55. Based on NICE guidance on cardiac conditions and independent clinical advice, we are of the view the Trust had a full overview of Mr D’s clinical picture and symptoms when reviewing the ECG test results.

56. Based on the above guidance and the lack of reported cardiac symptoms, we are of the view no further cardiac investigation, treatment or referral was clinically indicated.

57. It is important to acknowledge that where we have not identified any indications that something went wrong, it does not detract from the family’s experience, nor the impact this has had on them.

58. We understand the events complained about have caused Mr C and his mother a great deal of distress. Complaints give us valuable insight into the organisations we investigate, and we recognise this has been an emotionally challenging process for Mr C and his mother. We would like to thank him for sharing his experience with us.

1. We have carefully considered Mr C’s complaint about the Royal Orthopaedic Hospital NHS Foundation Trust (the Trust). We have not seen anything went seriously wrong. The records indicate the Trust acted in line with the National Institute for Care Excellence guidelines for cardiac disease when considering Mr D’s ECG results and medical history. We can also see the Trust acted in line with the Royal College of Anaesthetists guidelines when balancing the risk and benefit of surgery.

2. We understand it is Mr C’s firm belief that his father’s right bundle branch block and occasional atypical beats led to his death in March 2025. We acknowledge how difficult and upsetting this view is for him. We recognise how distressing this has been and hope the information below will give Mr D’s family further clarity about what happened and the relevant clinical standards available at the time. We offer our sincere condolences to Mr C and his family.