Trust did not make adequate follow–up plans for man with heart condition who later died

What happened

Mr A complained to us that his partner Mr W had gone to hospital and had not been admitted. He said he went back around two weeks later and again was not admitted. Mr A said if Trust staff had admitted Mr W, he could have been treated and would not have died.

What we found

The first assessment in A&E was not as thorough as it should have been. There were no failings in the assessments and care Mr W received on the second occasion, and none in the decision to discharge him.

There were failings in the discharge plan on the second occasion because staff did not make adequate arrangements to make sure that repeat blood tests were carried out, and they did not arrange a follow–up cardiology appointment.

Mr W's death could not have been prevented, but the failings meant that Mr A would always be uncertain about this, and this would have a long–lasting and upsetting effect on him.

Putting it right

The Trust apologised to Mr A for the failings, and agreed to draw up an action plan to explain how it would prevent a recurrence. The Trust agreed to share this plan with the Care Quality Commission, which is responsible for the inspection and regulation of hospitals.