Miss X said that her brother, Mr X, suffered from a congenital heart defect (“ACHD”) and had surgically treated kyphoscoliosos (a condition in which the spinal column is convex both backward and sideways). She complained about the insufficient regularity of investigations, notably Echocardiagrams (a diagnostic test that uses ultrasound waves to make images of the heart chambers, valves and surrounding structures) (“ECHOs”), leading up to October 2011. She said that if ECHOs had been carried out every six months, treating clinicians might have detected a sub aortic membrane (a form of fixed sub aortic obstruction in which a fibrous membrane is located below the aortic valve) earlier than January 2012.
Miss X also complained that her brother could not be put on the waiting list for surgery until all tests and investigations had been completed and this took 11 months. She said that her brother was inappropriately prioritised for surgery; she said that he should have been prioritised due to his kyphscoliosis and the effect this had on his ability to expand his lungs. Miss X said that this would not have been an issue had the investigative tests been undertaken within a reasonable time. She said that the failure to undertake ECHOs far more frequently and to undertake investigative tests within a reasonable time meant that her brother did not receive surgery in time to save his life. Mr X was 57 years old when he passed away.
The Ombudsman concluded that there was no evidence to suggest that ECHO tests should have been undertaken more frequently. This was in light of the fact that the degree of obstruction caused by Mr X’s sub aortic membrane (the narrowing of the left ventricle of the heart just below the aortic valve through which blood must pass) would have been unlikely to have been detected earlier than January 2012, which prompted the need for surgery. Given that there was no significant deterioration in Mr X’s condition between October 2011 and December 2012, the Ombudsman found that the Health Board did not prioritise Mr X for surgery inappropriately. The Ombudsman upheld the complaint about the clinical advice given to Mr X during his wait for surgery. There was no evidence that Mr X was made aware of worrying symptoms. The Ombudsman upheld the complaint regarding Mr X’s wait for treatment.
Treatment should have been supplied within 26 weeks, but Mr X was not due to receive treatment until 50 weeks had elapsed. Had Mr X received surgery more promptly, on the balance of probabilities, his death would have been avoided. The Ombudsman therefore took the view that Mr X’s death was avoidable.
The Ombudsman made the following recommendations:
a) That the Health Board’s Chief Executive personally apologises to Miss X for the failings identified in this report, most notably, Mr X’s avoidable death.
b) That the Health Board concludes its “mirror” process to that conducted under the “Putting Things Right” (“PTR”) in order to assess the level of compensation that it should offer to Mrs X in respect of the avoidable death of Mr X. The Health Board has confirmed that the file has already been shared with its legal department for this purpose and, with that in mind, it should conclude this process within three months of the date of issue of the report.
c) That the Health Board ensures that the British Heart Foundation leaflet entitled ‘Heart Valve Disease’ is given to every relevant patient at clinic and that the checklist is completed to reflect this, and that appropriate advice has been given. The Health Board should ensure that all Cardiology clinicians are aware of this requirement. Confirmation that all relevant clinicians are aware of the leaflet, have sufficient copies and are aware when it should be used, should be provided to his office within two months of the date of the report.
The Health Board agreed to implement the recommendations.
A full copy of the report is available below.