The care received
As a result of investigations for concerns over ongoing shortness of breath the deceased underwent a coronary angiography procedure, which demonstrated severe triple vessel coronary artery disease. A perfusion scan was undertaken which showed reversible ischaemia and following a Multi-Disciplinary Team (MDT) meeting she was accepted for coronary artery bypass grafting.
She was admitted to hospital and the surgery was carried out two days later. The next day, the deceased had increasing noradrenaline requirements, so an echocardiogram was requested and a limited echo showed markedly reduced left ventricular function (LVF). The ECG performed two days post operatively showed inferolateral ischaemia. Three days post-operatively she was recorded as suffering with pain, nausea and vomiting. Four days after surgery she was discharged to the ward, but she had not received intervention for the reduced function in the left ventricle.
Ten days after the surgery it was noted that the deceased was not feeling well and was deteriorating. An urgent echo and cardiology review was requested. A chest x-ray showed features of heart failure. The echo on this day confirmed poor LVF, severe mitral regurgitation (MR) and moderate tricuspid regurgitation (TR).
Just under one month later the deceased entered cardiac arrest and passed away. The post-mortem concluded the cause of death was, 1a – Vein graft thrombosis with acute myocardial infarction. 1b – Ischaemic heart disease (treated with coronary artery bypass graft surgery).
As appropriate, the hospital trust carried out an investigation.
The outcome of the investigation prompted further investigation by the Royal College of Surgeons.
Their investigation highlighted that a device (known as a VEST) had been used, during surgery, which was (i) not standard nor were they aware of any indication for unplanned use, (ii) had no specific guidance from NICE as to its use and (iii) whilst it could have been used as part of a randomised trial, the deceased was not understood to have been part of any such trial; this device was known as a VSET device. it was concluded that consent in this case fell short of the guidance for good practice on consent and potentially breached good medical practice; it did not align with the GMC’s guidance.
It was also recognised that there were also significant gaps in consultant input during the deceased’s inpatient stay, including in relation to managing and treating the on-going clinical problems and, in particular, in the latter stages of the deceased’s care. There was a failure to appreciate a changing clinical situation, and to escalate appropriately to the responsible consultant or other specialists. Significantly, this meant that there were missed opportunities to treat the deceased. In accordance with the duty of candour, the family were provided with a copy of the investigation report.
Natale Blunden, an associate in Shoosmiths’ serious injury team at the Thames Valley office in Reading was instructed, on behalf of the family, to investigate a claim.
Following a letter of claim it was admitted by the trust that that their failures contributed to the deceased’s heart failure and death and the family received compensation on behalf of the deceased’s estate.
Natalie Blunden said: said:
“This case highlights how a hospital trust’s adherence to the duty of candour can assist in the investigation of claims. In this case, because of the comprehensive findings of the Serious Untoward Incident Report and separate investigations by the Royal College of Surgeons, we were able to focus our investigations, obtain early admissions and conclude this claim without the need for protracted litigation. This results in a much better outcome for any claimant but particularly for families who are grieving as a result of losing a loved one.”
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