‘We must make sure this doesn’t happen again ’

A review of procedures at The Vic was ordered after an investigation by a health watchdog revealed a catalogue of mistakes were made in the man’s diagnosis and treatment.

Blackpool North and Cleveleys MP Paul Maynard today said Blackpool Teaching Hospitals NHS Foundation Trust needed to find out what went wrong and bring to book anyone who had made a mistake in the patient’s care.

And details of the incident, revealed for the first time in a new report, come after the trust’s own annual report revealed the number of ‘patient safety incidents’ – cases where patients could or did come to harm – increased to more than 10,900 in 2013/14, and 10 incidents resulted in the death of a patient.

The Parliamentary and Health Service Ombudsman looked into the tragic incident of the man’s death after his daughter was dissatisfied with the trust’s response to her complaint.

It has asked the trust to accept and apologise for its failings and produce an action plan to ensure it learned from its mistakes.

The trust has also agreed to pay her £2,000 after the woman complained the hospital had “failed to carry out appropriate investigations to diagnose and treat her father’s chest pain and told him that he could fly when he was unfit to do so.”

The ombudsman’s report, which refers to the man and his daughter only as ‘Mr A’ and ‘Mrs B’, tells how the man was taken to hospital by ambulance after complaining to his GP about chest pains.

On arrival in A&E he had heart and blood tests, and the next day he completed an endurance test on a treadmill – used to diagnose the heart disease which causes angina - before being discharged.

A week later he flew abroad for a holiday where he fell ill and was admitted to a local hospital where tests showed he needed a triple heart bypass.

But while waiting for surgery he suffered a heart attack and a stroke, and although the operation was performed, he died.

The ombudsman found that while doctors at Blackpool Victoria adequately assessed and treated the man’s symptoms, they:

n Wrongly diagnosed a ‘non-specific chest pain’ rather than unstable angina.

Failed to assess his risk of suffering an early heart attack and early death.

Failed to follow guidelines which categorised him as medium or high risk.

Arranged an ‘inappropriate’ exercise tolerance test.

Discharged him without reviewing his medication and with only a request to his GP to repeat the exercise tolerance test after his regular medication had finished.

Failed to give him information about his symptoms, proposed investigations and treatment, or advice about lifestyle changes – including guidance on foreign travel.

The ombudsman concluded Mr A had “been denied any opportunity to make his own choices and to receive treatment that might have saved his life.”

It added his daughter’s distress would be made worse by the uncertainly of never knowing whether he could have survived were it not for the hospital’s failings.

Mr Maynard said: “This is a deeply tragic set of events and one which must not be repeated.

“The most important legacy of this case must be for the hospital trust to review its procedures to ensure appropriate diagnosis and treatment for patients with unstable angina.

“When a patient presents with symptoms of angina all of us would expect that every opportunity possible would be taken to rule out the likelihood of a cardiac arrest 
occurring.

“It would appear on the face of it that this did not happen in this case so people will rightly be concerned.”

Mr Maynard said Blackpool had “an excellent heart unit with many talented staff.”

But he added: “I do not know in this case whether an individual was culpable or whether this was an issue with process but I want the hospital trust to thoroughly assess where the problem occurred to ensure this does not happen again.

“If it is a case of human error or a mistake they need to apply their disciplinary procedures.

“By and large the hospital does a good job and circumstances of malpractice and mis-diagnosis are rare.”

News of the incident comes weeks after another concerning incident in which The Gazette revealed how the hospital launched an investigation after diabetic patient Peter Swire, 78, from South Shore, complained staff had changed his medical records to read “do not resuscitate”.

Earlier this year, Local Healthwatch Lancashire demanded an explanation from the trust for the “steady increase in the number of incidents reported in the past four financial years”.

And in April watchdogs the Care Quality Commission told the hospital it must improve in four of eight areas inspected, including A&E, medical care, surgery and outpatients amid concerns over incident reporting, patient records and maternity care.

In June, it was revealed that the trust had significantly reduced higher-than-average death rates to below those expected of a trust of Blackpool’s size.

Gary Doherty, chief executive of Blackpool Teaching Hospitals NHS Foundation Trust, said improvements had already been made in the wake of the man’s death.

He said: “The trust can confirm the complaint was fully investigated and responded to in line with NHS complaints procedures.

“When local resolution has been exhausted the complainant has the right to contact the Health Service Ombudsman for a review of the complaint as happened in this case.

“This case dates back to January 2012 and the trust has complied with the ombudsman’s recommendations.

“A number of improvements have been made to cardiac pathways as well as the appointment of three further cardiology consultants.

“The trust takes every complaint received very seriously and always endeavours to constructively investigate each issue raised and ensure any lessons learned are shared among appropriate staff.”

For the year 2012/2013, 59 complaints were forwarded to the ombudsman involving the trust, of which five were upheld. The trust said figures for 2013/14 had yet to be verified.

The case was one of at least 16 investigations into the actions of local health providers by the Parliamentary and Health Service Ombudsman in 2013/14 after complaints from people in Blackpool, Fylde and Wyre – the figure could be higher because some are made via an advocate.

What is Angina?

Angina is caused by the narrowing of an artery supplying blood to the heart muscle.

Unstable angina is also caused by a lack of blood flow and oxygen to the heart and the NHS considers it a ‘medical emergency’.

People with unstable angina are advised not to fly, or at least to get some help at the airport and arrange in-flight oxygen to prevent symptoms getting worse.