Trust failed in its care of cardiac patient

What happened

In summer 2011 Mrs A was diagnosed with a serious heart condition and underwent surgery at the Trust the following month. Before her discharge, her consultant cardiologist said that she needed close follow up by her local team of cardiologists. However, staff did not make a referral.

In autumn 2011 Mrs A went back to the Trust as an outpatient for a routine appointment. She was admitted for treatment as her condition had deteriorated. Clinicians caring for her agreed she needed to see the consultant cardiac surgeon in his outpatient clinic. However, he was on leave and staff did not look for another surgeon, so Mrs A was not seen until later in the year, by which point she was accepted for urgent surgery. Sadly, Mrs A did not survive the surgery.

Mrs A's daughter Mrs D made a complaint to the Trust.

What we found

There were failings in the way Mrs A was discharged after surgery with no follow up arranged, and also in her discharge after a second admission. There was also a failure to consider or arrange a referral to an alternative surgeon.

Although we did not conclude that Mrs A's death was avoidable, we believed that she was deprived of the best possible opportunity to survive surgery and her family were distressed by this. The inappropriate discharge and inadequate follow up left Mrs A unsupported when her condition deteriorated, and this was also distressing for her and her family.

There were also failings in the way the Trust handled the complaint. Responses were delayed, updates did not have enough detail and there were inadequate messages in some responses. We concluded that this added to Mrs A's daughter's distress.

Putting it right

The Trust acknowledged its failings and apologised to Mrs D for them. It prepared an action plan which set out how it will improve its services. The Trust paid Mrs D £1,000 for the distress she suffered.