13. Before we decide if we should investigate a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. We have done this, and we have found the Trust has already done enough to put right the impact of these events.
14. In its response, the Trust has accepted a number of failings in its management of Mr H’s discharge arrangements. It has identified that the nursing documentation was poor. The nursing staff failed to document Mr H’s progress towards, and their involvement in, his discharge from hospital. It has accepted that it could find no evidence that the request for assistance with Mr H’s shopping was actioned. It also acknowledges that more thought should have been given to whether Mr H could have benefitted from patient transport rather than allowing him to travel home in a taxi.
15. We see from the Trust’s response that it has apologised for these failings. It has outlined the steps it has taken to raise the issue with the ward staff in question and embed more robust auditing and training practices to ensure such failings are prevented in the future. We have considered whether this was enough to address the impact of the failings later in this statement.
16. The Trust has not accepted that Mr H should have been placed in a hospice on his discharge. It highlights that Mr H’s palliative care assessment established he did not meet the criteria for such a placement, and that his intention was to return to his home at the earliest opportunity.
17. To consider if this view is correct, we obtained the palliative care assessment. This confirms the Trust’s account is accurate. The notes indicate that Mr H’s condition was not rapidly deteriorating, meaning that there was no indication that he was likely to die soon.
18. The assessment notes show consideration of Mr H’s ongoing medication needs and symptom management, and the plans put in place for his care. Mr H had confirmed that he would accept home hospice help when it was needed. The plan then put in place was to refer Mr H for an assessment for this after his discharge. He would be called later in the week, but he was told to call sooner if advice was needed. These notes are consistent with the view that Mr H was not deteriorating to such an extent that he needed hospice care at the time.
19. We can see that the clinical view of Mr H’s condition was that he was reaching the end of his life, although not imminently. We can also see that he had made his wishes clear about what he wanted. The assessment documents record that Mrs H had indicated he wanted to receive care at home, and that Mr H ideally wished to die at home. It is likely from the views he shared that he would have declined to go into a hospice from hospital if this had been offered at the time, and that he still valued his independence.
20. We know that Mr H had capacity to make decisions. He had made clear his intention to go home, and that knowing he was reaching the end of his life, he had made a decision to die at home. Consent is a vital part of clinical decisions. GMC Good Medical Practice places an emphasis on respecting patient right to choose, stating:
‘Good doctors work in partnership with patients and respect their rights to privacy and dignity. They treat each patient as an individual.’
‘You must respect your patient’s right to decide. If their choice of option (or decision to take no action) seems out of character or inconsistent with their beliefs and values, it may be reasonable to check their understanding of the relevant information … and their expectations about the likely outcome of this option and reasonable alternatives. If it’s not clear whether a patient understands the consequences of their decision, you should offer more support to help them understand the relevant information. But you must not assume a patient lacks capacity simply because they make a decision that you consider unwise.’
21. We see the Trust’s actions are consistent with GMC guidance. It accepted Mr H’s choice on how he wished to die and worked with him to start putting in place arrangements for care suited to his needs and choices. While the plan was agreed before discharge, it would be necessary to assess him in the home environment before that support was put in place. The records show this was to be organised in the upcoming days.
22. We have seen no evidence to indicate it was possible to predict that Mr H’s condition would change so soon after he got home. This appears to have been unexpected. The expectation was that he may have managed, with some assistance with his shopping, for some time after. As such, and in conjunction with his stated wishes, it would have been wrong to try and place him in a hospice before he went home.
23. As the notes indicate, a phone call later in the week was planned to start discussions on Mr H being assessed for home hospice support, when the time came that he was in need of it. Sadly, it appears that neither Mr H, nor the Trust, foresaw that he would take a turn for the worse the day after he was discharged from hospital.
24. There were some failings in the Trust’s management of Mr H’s discharge, mainly in relation to nursing documentation, assistance getting home, and with his shopping. We have not seen indications that avoiding any of these failings could have resulted in Mr H being placed in a hospice at the end of his hospital stay. This was dictated by Mr H’s clinical presentation before discharge, and his own stated wishes.
25. It is true that failing to arrange shopping assistance will have resulted in Mr H returning to a home with no fresh food. This was not ideal. Omitting this from his discharge planning will have been a lost opportunity to ensure he was as comfortable as possible once he got home. A lack of nutrition is unlikely to have been a factor in his sudden deterioration, as he had only been out of hospital for a day.
26. This point caused Ms A particular outrage, along with the fact that Mr H was admitted to a hospice that night and then died the next day. On balance, we believe that the actions taken to put right the failings by the Trust are reasonable. We have not seen indications that there is a systemic issue with discharges of this kind. This appears to be an individual case.
27. The apologies look honest and the actions to train and monitor staff are proportionate. Robust procedures exist to ensure a safe discharge, and the failing in this case was to not follow them. As the Trust has put in place stronger supervision and auditing measures it is difficult to see what more could practically be done.
28. We recognise how saddened Ms A was by the manner in which her client’s, Mr H’s, life ended. We can see how discovering he was found, alone and in distress by a neighbour, will have been distressing for her to learn of.
29. What we are seeing is that this event was unfortunately not foreseeable. The Trust had predicted that Mr H would need end-of-life care at some point but determined when he was in hospital that he was not quite at that point. We can see that appropriate arrangements had been made to assess him a few days after his discharge. Sadly, events overtook these plans and Mr H’s condition rapidly deteriorated. Such unexpected and sudden step changes can occur in patients with chronic, or terminal, health conditions. We have seen no evidence that the Trust could have anticipated that happening.
30. We hope our consideration of this complaint provides some measure of reassurance that, while there were failings in this case, these were not as impactful as feared. There were plans in place to support the end of Mr H’s life, which he had been involved in putting into place. While it would have been ideal for him to have been made comfortable in a hospice earlier, we can see that this would only have been possible with the benefit of hindsight, and not the information available to him and the Trust at the time of his discharge.