South Tyneside and Sunderland NHS Foundation Trust

2. We agreed to investigate the following specific issues. That the Trust:

· failed to fully and clearly communicate Mr A’s condition to him and his family between 21 December 2017 and 10 January 2018

· did not clearly communicate the extent and seriousness of Mr A’s cancer diagnosis on 11 January 2018

· did not notice or treat Mr A’s swollen feet and ankles for five days

· discharged Mr A on 12 February when he was not fit for discharge and without sufficient pain relief medication and

· tried to discharge Mr A four times when he was not medically fit.

3. Mrs T said as a result of what happened, Mr A fell at home and could not get up. Her husband had to ask a neighbour for help and Mr A sadly died less than 24 hours later. Mrs T has experienced distress at the thought that Mr A died alone and in pain. She says she is devastated that she was not there and will never know if Mr A could have been saved.

4. Mrs T said she does not think the Trust took the complaint seriously and the lack of information and transparency means she will never have full closure.

5. The outcomes Mrs T sought were apologies and explanations for what happened. She also sought service improvements to prevent a recurrence of what happened to people in a similar situation.

6. Mrs T’s husband, Mr T, has acted as her representative in this complaint. With her consent, he has shared her views, as written in this report. We thank the family for sharing their experience and views with us.

7. Mr A was admitted to hospital on 21 December with pain in his upper abdomen, loose stools, nausea and a cough. The Trust found evidence of infection and diagnosed possible sepsis. The Trust investigated to try and find the cause of Mr A’s problems and gave him intravenous (IV) antibiotics for recurring infections.

8. A CT scan (a scan which provides more detailed information than normal X-ray image) and an ultrasound scan (USS scans use sound waves to create a picture of the inside of the body) on 3 January confirmed lung cancer.

9. The gastroenterology consultant saw Mr A on 8 January. He explained the management of his condition would depend on the multidisciplinary team (MDT - a group of professionals from different disciplines who discuss the patient’s case).

10. The Trust put a care package in place and discharged Mr A on 10 January. The MDT met on 11 January and concluded that the CT scan showed the lung cancer had spread to Mr A’s ribs and spine. Mr A attended an outpatient appointment with the respiratory consultant later on 11 January. The Trust arranged a further appointment for 22 January and made a provisional appointment with a cancer specialist on 2 February.

11. Mr A was admitted again on 31 January with dizziness, chest pain and a urinary tract infection. Blood tests showed a high calcium level (often associated with malignancy such as cancer). The Trust gave him IV antibiotics, a blood transfusion and treated his high calcium levels successfully.

12. During this admission the Trust treated Mr A for leg swelling and gave him diuretics (medication designed to increase the amount of water and salt expelled from the body).

13. The Trust reviewed Mr A on several occasions during his admission and made plans on these occasions for his discharge. The Trust discharged him on 12 February with a care package in place.

14. Mr A phoned Mr T to say he was home on 12 February. Mr T told us when he visited, he found Mr A had slid off the sofa and was unable to get himself up. He said his whole legs were badly swollen and it took two people to lift him back onto the sofa. He said the care worker reviewed the situation and stated future visits would be a two-person team. Mr T left and returned in the evening to check on Mr A.

15. A paramedic informed the family the next day that Mr A had sadly died.

Communication between 21 December and 10 January

19. Mrs T told us the Trust did not communicate the seriousness of Mr A’s condition. Her concerns relate to the family not being aware about the spread of the cancer.

20. The relevant guidance about communication is GMC Good Medical Practice. Section 32 says ‘You must give patients the information they want or need to know in a way they can understand’.

21. The records show evidence of the Trust communicating with Mr A and his family. On 25 December we see the doctor wrote ‘explained to the family that he will continue to feel unwell with the infection’ and ‘we are waiting for the CT to give us more answers’.

22. The Trust noted the CT findings in the records on 3 January. The doctor discussed these findings with Mr A the same day ‘Explained to patient results of the scan… need to obtain tissue for a diagnosis’.

23. The Trust arranged for Mr A to see a consultant respiratory physician on 8 January. The records show the consultant shared the seriousness of his condition with him ‘We broke the news today to Mr A… We specifically explained to him that the samples have demonstrated features consistent with lung cancer, but the full extent cannot be fully deciphered…’.

24. The Trust sent Mr A a copy of the letter that gave full details of his condition and the plans for further investigation.

25. Taking the views of our first respiratory adviser into account, we found the communication whilst Mr A was an inpatient was in line with GMC guidance. The Trust shared details of Mr A’s condition with him as the details emerged. We do not uphold this part of the complaint.

26. We accept the family say they were not aware of the spread of the cancer and we know this has been distressing. We have looked more at this concern in the next section of the report.

Communication on 11 January

27. Mrs T told us the Trust told Mr A on 11 January he had ‘early stage lung cancer’, which was inoperable, but could be managed with chemotherapy. She said the Trust did not tell him the cancer had spread to his bones including his ribs and spine. She said if the family had known the extent of the cancer, they would not have let the Trust discharge him.

28. We looked at the records of this appointment. We can see the consultant met with Mr A and Mr T. The record of the appointment is detailed. It states the doctor gave Mr A his diagnosis, and that the Trust was considering chemotherapy. The record states the cancer was widespread. The Trust sent a copy of the letter to Mr A.

29. We cannot know exactly what was discussed or understood in this meeting. We understand the family’s recollection about what happened is different from the information in the medical records. We do not doubt the family’s account, but we are unable to resolve this difference in recollection.

30. The Trust has provided notes, made at the time, that show it shared the diagnosis with Mr A and Mr T. We have no reason to think these records are inaccurate so it would not be reasonable for us to discount them. We have also seen no evidence to show the Trust told Mr A he had early stage cancer.

31. From the information in the records we see no failings in the information the Trust shared. We found the communication was in line with section 32 of the GMC guidance (set out in paragraph 20 above). We do not uphold this part of the complaint.

32. We understand the distress the family feel, thinking they would have not allowed Mr A to be discharged if they had known and understood the diagnosis. As we go on to look at in paragraphs 43 to 50, the decision to discharge is one that is made by the medical practitioners. Whilst doctors do take patient’s and family’s opinions into account, the decisions are based on the patient’s condition and care needs at that point in time.

Swollen ankles and feet

33. Mrs T told us that on 31 January 2018 ambulance staff taking Mr A to hospital noted his feet and ankles were swollen. She said it was at least five days before hospital staff noticed this and started treatment.

34. The medical records show the Trust were aware Mr A had swollen legs when he was admitted on 31 January. The doctor who took Mr A’s history and carried out the initial examination wrote ‘mild pitting oedema to knees bilaterally’.

35. GMC Good Medical Practice says ‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must adequately assess the patient’s conditions, taking account of their history … where necessary, examine the patient’ and ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’. The records show the doctor took a history, examined Mr A and arranged tests and investigations.

36. Our second respiratory adviser told us there was no indication Mr A needed any urgent treatment for these swollen legs and so we can see the actions of the doctor were in line with the guidance.

37. The doctor who examined Mr A the next day also noticed his swollen legs, writing ‘ankle oedema’. Our second respiratory adviser said there was nothing to show the Trust needed to give treatment, and so the actions were in line with the GMC guidance outlined in paragraph 35.

38. Our second respiratory adviser explained the records show the cause of Mr A’s symptoms were being properly investigated, in line with the guidance. The doctors were aware Mr A had recently had a diagnosis of cancer and test results show he had low albumin (albumin is a protein that is made in the liver). These medical conditions can lead to fluid collecting in the legs and cause swelling.

39. For these reasons there was no need for any urgent investigation or treatment. The records do not show Mr A complained about the impact of the swelling, and the doctors were aware of the swelling and the probable causes. Our adviser said doctors would not necessarily treat swollen legs immediately or urgently. This would only happen if there was a specific reason, such as the patient’s skin breaking down, or their overall health being compromised. This was not the case with Mr A.

40. The records show a specialist nurse documented Mr A’s swollen feet on 5 February and suggested he raise his feet. The nurse also suggested diuretics to help with this. The ward-based nursing staff notified the doctor of this the same day. The doctor started diuretics (furosemide).

41. This is in line with The Code which says ‘respect the skills, expertise and contributions of your colleagues, referring matters to them when appropriate and ‘maintain effective communication with colleagues’.

42. A doctor prescribed a low dose of diuretics the next day. Our second respiratory adviser said there is no evidence Mr A needed treatment more urgently than this. We do not uphold this part of the complaint.

Discharge on 12 February

43. Mrs T was concerned the Trust had found Mr A fit for discharge on 12 February. She said this was despite him living alone and being in discomfort and pain. She said he was unable to walk normally due to his still swollen feet and ankles. Mrs T said her brother was only given paracetamol for pain relief, which was not sufficient for his pain. We recognise the memory of this is upsetting and we appreciate Mrs T sharing her account with us.

44. We found the discharge was in line with the DoH guidelines. Our nursing adviser explained the decision had involved the MDT, had been reviewed regularly and the Trust had involved Mr A and his family in the planning.

45. This was in line with the DoH guidance which outlines the importance of the MDT working collaboratively to plan care and ensure ‘patients and carers are involved at all stages of discharge planning’.

46. The records show the Trust addressed family concerns about Mr A’s mobility, ‘nursing staff discussed this with him explaining that Mr A was medically fit for discharge, that he would have good and bad days with his mobility and that four times a day visits and equipment were in place on discharge.’

47. Our nursing advice explained the clinical records also showed Mr A was medically fit for discharge. His NEWS score (a set of measures used to show clinical deterioration) was 3. The NEWS guidance explains that scores of under 4 have a low risk of clinical deterioration and would not cause any delay to discharge.

48. The discharge summary shows Mr A was prescribed paracetamol and codeine, which is a strong painkiller. Mr T told us he found no evidence of codeine in Mr A’s flat. We accept this account, but we cannot dismiss the written records. We cannot explain why Mr T found no codeine.

49. To summarise, the Trust had assessed Mr A as medically fit for discharge. The Trust had prescribed strong painkillers. He had been assessed and reviewed by an occupational therapist, a physiotherapist and the cancer specialist nurse. The Trust had discussed discharge plans with him and his family. There was no indication it was not safe to discharge him home to his warden-controlled accommodation with equipment and carer visits.

50. For these reasons we find the Trust’s decision to discharge Mr A was in line with the national DoH guidance and we do not uphold this part of the complaint.

Trust tried to discharge Mr A while he was not fit

51. Mrs T told us she was concerned the Trust had considered Mr A fit for discharge on at least four occasions.

52. Our first respiratory adviser looked at the medical records and noted the Trust had found Mr A to be medically fit for discharge on four occasions. The relevant guidance about whether someone is medically fit for discharge is outlined in the NICE guidance.

53. This explains that the criteria to be met before a patient can be discharged from hospital will vary from patient to patient. Once a patient has finished any specific treatment that can only be delivered in hospital, then the decision is made dependent on the care needs of the patient.

54. For this reason, the decision that someone is medically fit is just part of the picture. Our nursing adviser explained the other aspects of the decision making were in line with the guidance outlined in the DoH guidance. The Trust followed this guidance by discussing the plans with the family, following the MDT approach, and making a referral to district and Macmillan nurses.

55. To summarise, the evidence does not show the Trust tried to discharge Mr A while he was not fit. The MDT approach the Trust used on the four occasions when he was found medically fit for discharge was in line with the NICE and DoH guidance. The Trust consulted with the family and made the decision based on this overall view of Mr A’s medical and social care needs. We do not uphold this part of the complaint.

56. We thank Mrs T for sharing her concerns with us. We hope our report provides some reassurance to the family that the Trust acted in line with national guidance in the care and treatment it gave Mr A.

1. We have investigated Mrs T’s complaint about the Trust’s communication and the care and treatment it gave her brother, Mr A, between 21 December 2017 and 12 February 2018. We were sorry to hear about the impact this continues to have on the family. We have seen the Trust followed relevant guidance in the communication and care and treatment it gave. On this basis we do not uphold the complaint.