Man with heart problems was discharged from hospital after tests, but died before his operation

What happened

Mr H had breathing problems and tests showed one of his heart chambers was very weak. He was treated for heart failure, and then tests at Gloucestershire Hospitals NHS Foundation Trust found all three of his blood vessels supplying the heart muscle were severely blocked. After the tests, Mr H became very unwell and was admitted to hospital overnight. His cardiologist felt he needed a heart operation.

According to Ms H, Mr H was told he would have to wait two to three weeks for his operation if he stayed in hospital, or six to eight weeks if he was discharged and had the operation as a planned procedure. Mr H was discharged and his cardiologist wrote to a cardiac surgeon at University Hospitals Bristol NHS Foundation Trust, emphasising the need to prioritise Mr H's assessment for the operation because his condition was severe.

It was several weeks before University Hospitals Bristol NHS Foundation Trust received this letter, but when a cardiac surgeon saw Mr H, he arranged a scan to find out if Mr H was suitable for the operation. Mr H's operation was finally scheduled for 17 weeks after he was referred by the cardiologist. Mr H died from heart disease before he heard about the date for the operation.

Ms H said that she was left not knowing whether her father would still be alive if the operation had taken place within six to eight weeks. This had caused her significant upset.

Ms H wanted the Trusts to take action so that other patients or relatives would not go through the same distressing experience.

What we found

Mr H's condition was complex. There is no guidance or accepted good practice about whether he should have stayed in the Gloucestershire hospital for the operation, and so the decision to discharge Mr H was reasonable.

However, there was a lack of documentation about what Gloucestershire Hospitals NHS Foundation Trust told Mr H about the operation and his options before he was discharged. Also, there was an unnecessary delay in the arrangements for the tests needed before a decision could be made about surgery because the cardiologist did not speak to the surgeon. Overall, despite these shortcomings, we did not find the care and treatment was so poor as to be service failure.

The actions of University Hospitals Bristol NHS Foundation Trust were in line with national guidance that no one should wait longer than 18 weeks for treatment following referral to a specialist. Mr H's operation was scheduled for 17 weeks after his cardiologist referred him to the surgeon.

We did not uphold the complaint about either Trust.