Failure to manage a complication after surgery put patient at increased risk of heart attack

What happened

Mr C had surgery for oesophageal cancer. After the operation, he developed a complication in which fluid leaks from part of the lymphatic system. Doctors tried to manage the problem conservatively at first. However, this was unsuccessful and Mr C had another operation. During this operation, Mr C had a heart attack. He had treatment and was discharged home the following month.

What we found

There was no fault on the part of the Trust in relation to Mr C's fitness for surgery and his first operation. The Trust carried out appropriate tests on Mr C's heart before surgery. The operation itself was carried out in accordance with standard practice and the surgeons took all reasonable precautions to avoid the complication Mr C developed.

We found fault in how the Trust managed the complication because clinicians managed it conservatively for too long before Mr C's second operation. We could not say if the delay in carrying out the second operation caused Mr C's heart attack, but it put him at greater risk. This was an injustice to Mr C because he will never know whether his heart attack could have been avoided.

There was also fault in relation to Mr C's take‑home medication, for which the Trust had already apologised.

Putting it right

The Trust apologised to Mr C and paid him £1,000 compensation. It also prepared an action plan to stop a recurrence of the faults we identified.

The Trust told us that as direct result of Mr C's complaint, it had introduced a new protocol to deal with the complication he experienced.