Decision Report 201904853

Summary

C’s parent (A) had a history of heart problems and suffered a cardiac arrest. Investigations at that time led to a diagnosis of deep vein thrombosis (DVT, a blood clot in a vein). Four years later, A’s heart condition had deteriorated and they were assessed for a possible heart transplant. These investigations indicated severe pulmonary oedema (a condition caused by excess fluid in the lungs) and significant emphysematous changes (emphysema is a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness) which meant A was not a suitable candidate for a transplant. The presence of emphysema was previously unknown to A. A died the following year due to heart failure with emphysema listed as a secondary cause. The doctor completing A’s death certificate found mention of mild emphysematous changes in the discharge letter around the time of the diagnosis of DVT. This was the first time A’s family had been made aware of these early findings.

C complained about A’s care and treatment. The board responded that mild emphysema is a very common incidental finding in CT scans of patients, such as A, who are cigarette smokers. The board said the degree of emphysema found was mild and would not have contributed to A’s symptoms or altered the plan for investigation at the time or the care provided to A subsequently. The board gave their view that there was no treatment that could have been offered that would have prevented the progression of the emphysema. The board apologised that they did not provide more information to A about the results of the CT scan at the time and advised that the case had been shared with the cardiology team and the importance of scan results being discussed with patients and recorded in their notes had been reinforced. C was unhappy with this response and brought their complaint to this office.

We took independent medical advice from a consultant in respiratory and general medicine. We found that, although the discharge letter included mention of mild emphysematous changes, emphysema was not included in A’s list of diagnoses and this meant that the board did not reasonably record the findings of the scan in A’s medical records and that a formal diagnosis of emphysema should have been recorded. We also found that A was not reasonably informed of the finding of emphysema or given any of the information recommended in the relevant guidance beyond general smoking cessation advice. While we also noted that stopping smoking was the only effective treatment available for emphysema, what cannot be known is whether a formal diagnosis of emphysema would have had any effect on A’s ability to stop smoking.

We also found that a reduced gas transfer result should have been followed up with a CT scan of A’s lungs. However, this would not have changed A’s treatment or overall outcome.

Overall, despite the board’s failures, C received treatment compliant with relevant guidance and these failures did not materially impact the subsequent progression of the disease or A’s eligibility for a heart transplant. On balance, however, we upheld the complaint that the board’s treatment of A unreasonably failed to take into account the finding of mild emphysematous changes in A’s early scan.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the specific failings identified. The apology should make clear mention of each of the failings identified and meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Relevant board staff are aware of the relevant guidance in respect of incidental findings of emphysema on CT scans and of the need to follow up significantly reduced gas transfer results with a CT scan of the lungs.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.