Avoiding diagnostic delays in heart failure

To help reduce the risk of a delayed or missed heart failure diagnosis, we examine cases involving heart failure in light of a new report from the British Heart Foundation.

According to a recent report by the British Heart Foundation (BHF), hospital admissions for patients with heart failure have risen by 33% over the last five years; three times faster than the overall rise in admissions to hospital in the same period. 

This may be explained by the increase in our aging population, and the fact that more patients are now surviving heart attacks or living with conditions like hypertension and diabetes, and developing complications as a result of them.

Delays in diagnosis can be due to the vague and non-specific signs and symptoms that patients may present with to their GP. This results in multiple visits to the GP, and in some cases the diagnosis is eventually made through emergency admission or an acute event. According to their research, the BHF found that nearly eight in ten patients had visited their GP over the previous five years with symptoms associated with heart failure, such as breathlessness, swollen ankles and exhaustion, but were not diagnosed before hospital admission.

The BHF is calling for improved ways of diagnosing and managing heart failure and wants GPs to have greater access to specialist blood tests and heart scans to allow the diagnosis to be made earlier. Ashleigh Li, senior cardiac nurse at the British Heart Foundation, said:

'Delayed diagnoses can significantly worsen a patient's quality of life, and that's why we are calling for GPs and other healthcare professionals who work in the community to have greater access to specialist investigations required to detect and diagnose heart failure. This will not only improve thousands of lives, but relieve the unsustainable pressure that heart failure is putting on our health service.

'Our research aims to harness the potential of regenerative medicine to reverse and cure heart failure, but it is going to take some time before our research breakthroughs are translated into viable treatment options for heart failure patients.

'In the meantime, we must ensure everyone affected receives a timely diagnosis and the best standard of care.'

MDU cases

Seventy one incidents involving heart failure were reported to the MDU in 2018 and 2019.  Common causes of complaints and claims were allegations of a missed or delayed diagnosis and prescribing errors which either led to or made the patient's heart failure worse. The findings from the incidents included the following points.

  • The age ranges of the patients diagnosed with heart failure ranged from 41 to 92 years.
  • Nearly half of the incidents (48%) related to complaints and 27% related to requests for support with coroner's inquests. 17% of the cases involved a  claim for clinical negligence having been made, with 13% of these being against GPs and 4% being NHS trust claims. In 3% of cases members were asking for assistance in preparing an adverse incident report and 3% with assistance where a patient or family member had made a complaint to the GMC.
  • 71% of the cases related to patients seen in general practice with a small number of these (3%) being seen by a nurse practitioner, rather than a GP. Other specialties included general medicine, cardiology, emergency medicine, endocrinology, anaesthetics, respiratory medicine and cardiothoracic surgery.

The majority of cases involved patients presenting with shortness of breath and reduced exercise tolerance. In a number of cases, the patient was diagnosed with a chest infection and prescribed antibiotics. Complaints often focused on communication problems, refusal to carry out a home visit, failure to arrange appropriate follow up and failure to admit to hospital.

A number of cases involved prescribing errors, resulting in the development or worsening of heart failure due to polypharmacy, incorrect dosage or using medication that was contraindicated in patients with heart conditions. Past medical or family history was often not asked about or recorded in the records and patients were not questioned about other risk factors for heart disease. There were a small number of cases where a diagnosis of heart failure was delayed in patients with other comorbidities, such as amyloidosis and phaeochromocytoma.

Delayed diagnosis

Failure to diagnose heart failure is not necessarily negligent but a claimant may have a case if they can show that a doctor's management fell below the expected standard; for example, by not actively considering the possibility of heart failure when a patient presents with typical signs or symptoms, particularly if these are ongoing or recurrent.

To help reduce the risk of a delayed or missed heart failure diagnosis, we advise the following.

  • Be aware of the NICE guidance on the diagnosis and management of heart failure.
  • Make sure any patient consultations about non-specific signs and symptoms are clearly documented, including the history taken, length of time the patient has been experiencing the symptoms and the variation and pattern of symptoms, examination performed, the differential diagnosis and the management plan.
  • Take into account a patient's past history of heart problems or of similar symptoms and any risk factors for heart disease. Check the records of earlier attendances and consider whether a previous history of similar symptoms could be related.
  • Ask about family history of similar symptoms and significant illnesses and risk factors.
  • Check that any medication you prescribe is not contraindicated in patients with heart disease and that it is safe to prescribe in combination with other medication the patient may be taking.
  • Check that the patient understands plans for follow-up, including the importance of any red flags, and that these are also clearly documented.
  • Consider continuity of care and, where possible, ensure follow up appointments are with the same doctor.
  • If you consider you need further training in the diagnosis and referral pathway for heart failure or other cardiac conditions include this in your personal development plan and appraisal.
  • Where a referral has been made, particularly if it has been made urgently, it's advisable to have systems in place to check that an appointment follows, so that no-one is lost in the system.
  • Your practice should also have a safe system for following up test results, including a process for responding to abnormal results and making sure these are communicated to patients.
  • Have in place a protocol for dealing with administrative tasks, such as dealing with messages to and from patients. Protocols are a helpful statement of the standard of care to be provided and a definition of responsibilities within the team.
  • Ensure the practice has a robust system, such as a significant event audit, for analysing patient safety incidents. This can highlight lessons that can be learned and what changes should be put in place to prevent a similar situation in the future.
  • Provide patients with an explanation and apology if something does go wrong, particularly if the outcome is poor or unexpected. Take steps to deal with the consequences and arrange appropriate treatment and follow-up. Also, contact the MDU for advice and support at the earliest opportunity.

This guidance was correct at publication 02/12/2019. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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