Failure to carry out echocardiogram led to missed opportunity to provide relevant treatment

Organisation we investigated: Gloucestershire Hospitals NHS Foundation Trust

Date investigation closed: 06 September 2019

The complaint

Complainant Q complained about the care and treatment provided to Person V, specifically that:

  • Doctors wrongly diagnosed emphysema (a chronic lung disease) as the cause of Person V’s breathlessness
  • The Trust could not provide an echocardiogram at the weekend
  • The Trust discharged Person V although they had not had an echocardiogram
  • The Trust did not do enough to arrange an urgent echocardiogram once Person V had been discharged
  • The Trust had not acknowledged any failings.

Complainant Q said that Person V had a heart attack shortly after being discharged and died. Complainant Q said that Person V was denied the best chance of survival because of failings by the Trust. 

What we found

The Trust’s initial assessment of Person V was in line with the relevant guidelines. Doctors reached the correct diagnoses, based on the information from the tests they carried out.

However, the Trust should have performed an echocardiogram. Guidelines say an echocardiogram should be performed within 48 hours of new, suspected heart failure, which is what Person V’s diagnoses amounted to. The Trust should have kept Person V in hospital until the Monday to do the echocardiogram. It was also more urgent to give her an echocardiogram as Person V had been experiencing symptoms for about a month before their admission.

The Trust did not recognise the urgency of Person V’s condition. Discharging them without performing an echocardiogram, or at least arranging an urgent echocardiogram, was wrong. The discharge letter to Person V’s GP did not convey any urgency in the need to arrange an echocardiogram. 

By not performing an echocardiogram, the Trust missed an opportunity to diagnose the extent of Person V’s illness and provide relevant treatment. However, we were unable to say whether Person V’s tragic outcome could have been prevented.


Person V, an older person, had experienced breathlessness on exertion for about a month. V then went to stay with Complainant Q and started to experience breathlessness, overheating and nausea. Complainant Q took advice from a GP and Person V was reviewed by a paramedic. They told Person V to go to A&E at the Trust.

Person V was reviewed in A&E. They had blood tests, and an electrocardiogram, a CT scan and a chest X-ray. The Trust did not have echocardiogram facilities on site. The Trust was able to provide outpatient echocardiogram tests at a different site at the weekend, but the doctor reviewing Person V was unaware of this. Person V was admitted to the acute admissions unit.

Doctors recorded an initial diagnosis of pulmonary oedema (fluid on the lung) as a result of undiagnosed heart valve disease. This was updated to aortic stenosis the following day, followed by community-acquired pneumonia and finally emphysema. 

Person V was then discharged, and doctors advised her to seek follow up from their GP. They went back to their own home that day. Person V saw their GP and requested an echocardiogram but was unable to get one as the Trust’s discharge letter did not say they needed one.

A few weeks later, Person V had a heart attack. They were taken to their local hospital (run by a different trust). Person V had urgent surgery to replace a heart valve and had a coronary artery bypass but died a few days later.

Putting it right

The Trust demonstrated learning from the complaint and has ensured echocardiogram equipment is available. However, we considered the Trust had not fully acknowledged the extent of its failings.

We recommended the Trust wrote to Complainant Q to acknowledge and apologise for the failings we found. We also recommended the Trust put together an action plan to further improve its service around recognising the urgency of treating aortic stenosis and providing an echocardiogram within 48 hours of admission.

We also recommended the Trust pay Complainant Q £4,000.

The Trust complied with our recommendations.

This case summary is featured in the Ombudsman's Casework Report 2019.