Why Idris is on the list
- Record review
- Review recommended
- Unplanned hospital episodes
- 2 in the past year
- Most recent 26 Aug 2026
- Conditions recorded
- Heart failure
- Care planning
- No advance care plan
- Not on the palliative care register in this record source
2 indicators present in the record
2 emergency admissions in 12 months (most recent 26 Aug 2026)
Shaped after SPICT general indicator GEN_ADMISSIONS
Recorded 26 Aug 2026Heart failure found in a discharge summary on 26 Aug 2026: "Acute breathlessness and increasing peripheral oedema in established heart failure.". NYHA class is not recorded in this record source.
Shaped after SPICT heart and vascular indicator, adapted: NYHA class is not present in this record source REC_HEART
Recorded 26 Aug 2026
Screening
No screening has been run for this patient.
Record review
The record supports a prompt clinical review for a goals-of-care conversation.
Prompt human review is supported for a sensitive goals-of-care conversation alongside active disease management. The record shows progressive congestion symptoms followed by an urgent attendance for acute decompensated heart failure, IV diuresis, and residual cardiorenal vulnerability at discharge. Improvement with treatment is reassuring but does not remove the value of discussing priorities, acceptable care, and escalation preferences; the record does not document an active advance-care plan.
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What the record shows
Progressive heart-failure symptom burden
Ankle oedema and weight gain progressed to nocturnal breathlessness, slower walking, orthopnoea, and an urgent acute-care presentation, supporting timely review of priorities as well as clinical treatment.
3 sources in the record
- Eligible9 May 2026
GP review recorded evening ankle swelling and a 2 kg weight increase in the context of heart failure and CKD review.
- Eligible18 Jun 2026
Community visit recorded waking with breathlessness, slower walking, mild ankle oedema, and increased weight.
- Eligible17 Aug 2026
Hospital attendance recorded orthopnoea and worsening swelling with pulmonary vascular congestion.
Recent decompensation requiring hospital treatment
The need for IV diuresis and subsequent specialty follow-up indicates a clinically consequential episode rather than an isolated minor symptom report.
2 sources in the record
- Eligible17 Aug 2026
Acute medical unit attendance was urgent and IV loop diuretic treatment was started.
- Eligible26 Aug 2026
Discharge summary identified acute decompensated heart failure with cardiorenal vulnerability.
Cardiorenal vulnerability during congestion
Renal deterioration and potassium elevation can constrain heart-failure treatment and increase the importance of coordinated planning and clear escalation arrangements.
2 sources in the record
- Eligible29 Jul 2026
Renal and congestion report recorded creatinine 98 µmol/L, eGFR 58 mL/min/1.73m², potassium 5.5 mmol/L, NT-proBNP 3560 ng/L, and same-week heart-failure assessment.
- Eligible26 Aug 2026
Discharge summary stated renal function remained below baseline and potassium required surveillance.
What they and their family want
- Telephone is the recorded contact preference.
- The patient's goals, understanding, preferred place of care, treatment-escalation preferences, and people they wish to involve are unknown.
- Family or carer identity, availability, views, and permission to contact them are unknown.
- Decision-making capacity, health and welfare attorney status, and the presence of legal or emergency-care planning documents are unknown.
2 sources in the record
- Eligible30 Jun 2026
Administrative observation recorded telephone as the contact preference.
- Collection manifest12 Sept 2026
Coverage is limited to one eligible frozen snapshot of 37 resources, so undocumented wishes, supporters, capacity, and legal planning remain unknown.
Care at present
Home is the documented follow-up and monitoring setting, but the exact residence and living arrangement are unknown.
Walking was documented as becoming slower during increasing breathlessness; usual mobility, activities of daily living, frailty, cognition, and baseline independence are unknown.
- GP review and follow-up actions are documented.
- Community home visiting is documented.
- Hospital treatment for acute decompensated heart failure is documented.
- Heart-failure and renal clinic review was requested after discharge.
- Current symptom status after discharge is not documented beyond post-discharge laboratory results.
- Completion of the requested one-week heart-failure and renal reviews is not documented.
- Usual functional baseline, formal care package, medication list, adherence, family support, and home monitoring results are not documented.
2 sources in the record
- Eligible18 Jun 2026
Community home visit documented slower walking during increasing nocturnal breathlessness.
- Eligible26 Aug 2026
Discharge plan arranged daily weights at home plus GP, heart-failure, and renal follow-up.
Clinical decision support only. A named clinician decides. Generated 12 Sept 2026, committed for the demonstration; wording adjusted to Cairn's language rules where the review used terms Cairn avoids.