Discharge
15. Miss N complains that her mother was unsafely discharged from the Trust on 11 June 2019. She says her mother was not well and she was not consulted before the discharge. Miss N also says an appropriate support package was not in place and her mother was discharged with tablet medication, not soluble medication.
16. The Trust said it cannot find records to show it adequately discussed Mrs N’s discharge with Miss N and that soluble medication was not provided.
Medication on discharge
17. Adviser 1 explained that the decision for discharge is based on a doctor’s clinical judgement after considering all factors in a patient’s condition. They said the information in Mrs N’s medical records show she was medically fit for discharge from the Trust on 11 June 2019. Mrs N was reviewed by the medical team on 11 June 2019 and the team felt she was well enough to go home. Additionally, Mrs N’s National Early Warning Score (NEWS) score was 1.
18. The NEWS score is a tool used by medical professionals to quickly establish how ill a patient may be and improves the detection and response to clinical deterioration. This is based on physiological parameters such as blood pressure and respiratory rate. A lower score means a patient is more likely to be well.
19. Mrs N’s NEWS score showed her physiological parameters, including pulse, blood pressure, temperature, and respiratory rate, were in an acceptable range for her to be discharged from hospital.
20. On 11 June 2019, there were some concerns from the nursing team regarding Mrs N’s continence. The medical records show the nursing team contacted Miss N about this and she explained this was an ongoing issue and it was managed at home with continence pads.
21. The General Medical Council (GMC) ethical guidelines for doctors state that doctors must adequately assess the patient’s conditions, taking account of their history and provide effective treatments based on the best available evidence. The available information shows the Trust properly assessed Mrs N before her discharge and the information available to the Trust showed she was fit for discharge on 11 June 2019.
22. Based on the above information, Mrs N was medically fit for discharge on 11 June 2019. We recognise Mrs N’s health deteriorated soon after arriving home and this will have been very upsetting for Miss N. While not wishing to diminish the impact this had on Miss N, there is no information to show Mrs N was not medically fit for discharge. Therefore, the Trust acted in line with GMC guidance and there are no failings in this part of the complaint.
Discharge planning
23. When Mrs N was admitted to hospital, it was recorded that she lived with her daughter, was bed-bound, and had a care package for four visits per day (QDS). It is not documented in Mrs N’s records whether she had one or two carers supporting her. District nurses also saw Mrs N to manage a pressure ulcer.
24. The relevant guidance here is the Trust’s discharge policy. Adviser 2 explained that, based on Mrs N’s care needs, her discharge from hospital would have been considered a ‘simple discharge’. It would be considered simple as it would have involved minimal disturbance to Mrs N’s activities of daily living. Also, it would not have prevented or hampered a return to her usual place of residence and would not have required a significant change in support offered to her or her daughter in the community.
25. The discharge policy states that, when a patient is admitted to hospital, an initial assessment and discharge plan must be completed by a registered health professional within 24 hours of admission. Appendix 2 of the policy shows the discharge planning document which must be completed. Adviser 2 said there is no information to show the Trust completed an assessment or discharge plan document for Mrs N.
26. The discharge policy also states if a patient has an existing care package which needs to be restarted, the registered health professional completing the assessment will need to contact social services to establish the most appropriate way to restart the package. The policy also states social services need to be informed 48 hours before restarting a care package. Adviser 2 says there is no information to show the Trust made a social services referral regarding Mrs N’s care package.
27. Mrs N’s records show nurses spoke with Miss N on 31 May 2019 about the care package. Miss N confirmed she was happy with the current care package. After this, the only other reference to the care package in Mrs N’s records are on the day prior to her discharge. Here it is noted that Miss N had rebooked the carers for Mrs N.
28. The guidance states, “communication with care providers must be documented in the patient’s health records and the discharge summary must include any infection risks and associated care needs”. Adviser 2 says there is no information to show nursing staff spoke with the care providers or district nurses before Mrs N was discharged.
29. Additionally, the policy identifies the need for the patient and carer (this can include informal care such as family members) to be central to the discharge plan. It states they must be kept up to date with progress on a regular basis by all members of the multidisciplinary team (a group of health care professionals managing a patient’s care). There are multiple entries in Mrs N’s records which show doctors and nurses discussing Mrs N’s ongoing care and management with Miss N.
30. However, throughout Mrs N’s hospital stay, there are no recorded discussions between doctors and nurses and Mrs N or Miss N, about discharge planning. The only entries in the notes showing communication with Miss N about discharge planning are about her rebooking carers (as noted above) and her being informed of the discharge and the time Mrs N left the ward.
31. Based on the above information, the Trust has not adhered to its discharge policy. While it kept Miss N up to date on her mother’s medical condition, the information shows it did not complete an assessment and discharge plan on Mrs N’s admission to the ward. There is also no evidence that the Trust included Mrs N or Miss N in its discharge planning.
32. The Trust also did not communicate with social services or Mrs N’s care providers to ensure the care package would be restarted on discharge and the carers could carry out the package. We appreciate Miss N arranged for carers to be present on discharge. However, this was a task which should have been completed by the Trust. Therefore, this falls so far short of the Trust’s discharge policy, that it is a failing. We discuss the impact this had on Mrs and Miss N in the section below, called ‘Impact’.
Medication
33. Adviser 2 said there is limited national clinical guidance on this matter so staff should ensure a patient is provided with medication in line with any local policies concerning medicines on discharge. The Trust’s discharge policy does not reference types of medication for discharge. It does state all medication requests should be sent to the pharmacy at least 24 hours in advance of a discharge.
34. Mrs N’s medical records do not reference whether medication for her discharge was ordered 24 hours in advance. The only reference to medication for discharge is documented in the early morning on 11 June 2019, the day of discharge. Here it is noted that soluble prednisolone (steroid medication) was unavailable so nursing staff ordered it from the pharmacy. This shows the Trust did not adhere to its discharge policy as staff had not ordered Mrs N’s discharge medication 24 hours in advance.
35. As there is no national guidance to assist us, we have considered the Nursing and Midwifery Council (NMC) Code and our Principles.
36. Section 10 of the NMC Code says clear and accurate patient records must be maintained. Specifically, section 10.2 states staff must “identify any risks or problems that have arisen, and the steps taken to deal with them, so that colleagues who use the records have all the information they need”.
37. Mrs N’s records show she was taking several liquid medications prior to her admission to the Trust. During Mrs N’s hospital stay, Miss N also raised concerns about her mother taking tablets. There is no information to show the Trust addressed this or documented it in Mrs N’s record.
38. Yet, as referenced above, on the day of discharge, it is recorded that no soluble prednisolone was available. It was also documented the day earlier that prednisolone was dissolved for Mrs N. This shows the Trust was aware of Mrs N’s medication requirements. Unfortunately, Mrs N was still discharged with oral tablet medication.
39. While we have not seen information to show Mrs N’s requirements were documented, staff were aware of this risk. This means the Trust only partially acted in line with section 10.2 of the NMC Code. The nursing team should have clearly documented this to ensure all staff adhered to this need. The Trust still discharged Mrs N with tablet medication which shows it did not fully act on the information that was available to it.
40. Our Principles of Good Administration, specifically ‘Being customer focused’ say “public bodies should do what they say they are going to do. If they make a commitment to do something, they should keep to it, or explain why they cannot”. The Trust did not adhere to our Principles as it knew soluble medication was required but it did not provide this to Mrs N on her discharge from hospital.
41. Therefore, the Trust’s actions were so far short of its local discharge policy and our Principles that it is a failing. We discuss the impact this had on Mrs and Miss N in the section below, called ‘Impact’.
Impact
42. When we identify failings during an investigation, we see whether this has had an impact on the complainant and whether the organisation has already put this right. Miss N says she feels let down by the Trust and feels responsible for her mother’s death. She says her life has been profoundly affected and it has been very distressing. Miss N also says her mother suffered greatly when she did not need to.
43. We acknowledge that a lack of preparedness for discharge and the medication issues, will have been distressing for Miss N. We recognise Miss N will have been anxious about how to or whether she should administer the tablet medication. We also recognise these failings will have left Miss N feeling let down by the Trust.
44. After speaking with Miss N about the events, she feels the events affected her mother’s health. We appreciate this has been an extremely difficult time for her. While not wishing to diminish how the events affected her, we have seen no information to show her mother’s health was severely affected by the failings we have identified.
45. We note the Trust has acknowledged failings in record keeping, communication and medicines management. The Trust’s 5 November 2019 complaint response says it cannot find records to show it discussed Mrs N’s discharge with Miss N. It says it needs to ensure all staff conversations are recorded properly. The complaint response also says that Miss N had provided a GP summary on admission which supported that her mother needed soluble medication.
46. The Trust says it has taken action to ensure these events will not happen again. It says nursing documents have been updated and staff have been reminded of the need to document conversations with patients or their relatives. It has reviewed its discharge procedures and extended its regular document audits to cover nursing, medical and therapy notes.
47. The Trust has also implemented a double check process for medications on discharge and improved guidance and clarity for staff to ensure medication is provided in the appropriate form (tablets or liquid).
48. Adviser 2 reviewed these actions and said these are reasonable and the audits should lead to quality improvements in the areas where failings have been identified. The Trust has also completed a robust investigation and has taken Miss N’s complaint seriously. It has also apologised to Miss N for these failings. While we appreciate these were not in place when Mrs N was in hospital, it shows the Trust has taken appropriate action, in line with our Principles of Remedy.
49. However, while it is pleasing to see that the Trust has already implemented service improvements and apologised for the failings we have identified, it has not acknowledged and apologised for the impact these had on Miss N. For this reason, we consider the failings are linked to the distress and feeling of being let down that Miss N experienced. Therefore, these parts of the complaint are upheld.