Discharge 22 May
16. Miss K says the Trust incorrectly discharged her mother on 22 May, despite her not being fit for discharge, only to admit her later the same day. She says her mother was inappropriately discharged with a catheter in place. She says this caused her mother’s condition to deteriorate, which contributed to her mother’s death.
17. Mrs C had a history of chronic obstructive pulmonary disease (COPD), pulmonary fibrosis and shortness of breath with minimal activity. She also had severe respiratory disease and acute on chronic kidney disease. The Trust catheterised Mrs C for comfort during the admission and discharged her with the catheter in place, planning for a trail without catheter and catheter removal from the district nursing teams. We have sought clinical advice about whether Mrs C was fit for discharge on 22 May.
18. The Department of Health and the NHS outlines a patient is fit for discharge when they reach a point at which their care and assessment can be continued in a non-acute medical setting.
19. A patient’s NEWS is used to provide guidance about the patient’s recovery and return to stability, which should be used when considering whether they are fit for discharge. The RCP guidance explains NEWS is based on a simple combined scoring system and a score is given for six physiological measurements: respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new confusion and temperature. The guidance explains for patients who have respiratory failure, the normal parameters can be altered when completing NEWS observations.
20. As Mrs C had respiratory failure, the records show, on 21 May, the Trust altered the unacceptable parameters for a respiratory rate to rise above 30, oxygen saturations to reduce below 88%, a systolic blood pressure below 100mmHg, and a heart rate above 110. This is in line with the RCP guidance and our clinical advice supports this view.
21. We can see Mrs C was treated during this admission for a flare-up of her lung disease, an Acute Kidney Injury (AKI) and dehydration. On 21 May, Mrs C had a blood test, which show she did not have any significantly raised inflammatory markers. This is a sign of infection. Her respiratory rate was 26, her oxygen saturations were 89%, her systolic blood pressure was 123 and her heart rate was 88. We can see from the clinical records on 22 May, her oxygen saturations were 91%, her heart rate was 88 and her overall NEWS had improved and was back within her normal range.
22. From reviewing the records, Mrs C’s NEWS throughout this admission are within her acceptable parameters. Our physician adviser explains, if a person’s test results are improving this would suggest they are medically fit for discharge. Based on the evidence available, we can see between 21 and 22 May, Mrs C’s NEWS improved, and this would suggest she was physiologically stable. Our adviser explains at the time of discharge, Mrs C did not have any increased care needs.
23. Taking this advice into consideration, we consider based on the DoH and NHS guide, Mrs C was clinically fit for discharge, as she was physiologically fit, with an increasing NEWS and test results and she required no additional care needs that required treatment in an acute setting.
24. Miss K also raises concerns that her mother was discharged with a catheter in place. As explained above, the DoH and NHS guide explains a patient is fit for discharge if their care can be continued in a non-acute setting. The records show the Trust discharged Mrs C back into the care of her care home and planned for a follow up review with the district nursing teams for a trial without catheter, and removal of the catheter if this was successful.
25. The NICE guidance explains the person’s clinical need for catheterisation should be reviewed regularly and the urinary catheter removed as soon as possible to ensure there is a minimum risk of infection.
26. We can see throughout the admission the records show the Trust checked the catheter daily for redness and ensured the catheter was draining appropriately. Our adviser explains the Trust has provided appropriate catheter care throughout Mrs C’s admission. As Mrs C was clinically optimised for discharge and physiologically fit, the Trust discharged Mrs C with the catheter in place. To ensure Mrs C received appropriate catheter care following her discharge, we can see on 22 May, the Trust contacted the single point access referral team (a local team providing support for care) to arrange for a trial without catheter after returned to the care home, and eventual removal of the catheter when it was appropriate.
27. We can see from the records, the Trust gave thorough consideration to the safe removal of the catheter at a time when it was appropriate. A trial was arranged with the district nursing team to try Mrs C without a catheter. We are satisfied the Trust thought about how best to remove the catheter when it was appropriate and consider the Trust has acted in line with NICE guidance about catheter care to prevent infection and provide appropriate care. Our clinical advice supports this view.
28. We understand how distressing it must be for Miss K to feel as though her mother was not fit for discharge on 22 May, and her concerns this contributed to her mother’s death. This must be very worrying for her, and she has understandably explained how this issue is still upsetting her. We are satisfied upon discharge, on 22 May, Mrs C was physiologically stable, and did not have any increased care needs which could not be managed in a non-acute setting, and our clinical advice supports this view. We hope this provides Miss K with reassurance over the Trust’s decision to discharge her on 22 May. We do not uphold this element of the complaint.
Residential care setting
29. Miss K says the Trust discharged her mother into the wrong residential care setting on 22 May. She says as her mother was approaching the end of life stage it was not appropriate for to be readmitted to the care home, as it could not provide appropriate care for her needs. She considers a nursing home or hospice would have been more appropriate for her.
30. We understand why this issue is so important to Miss K and she has explained how difficult it was for her to come to terms with her mother’s passing and her concerns over whether she should have been sent to a hospice or not towards her end of life.
31. The NHS page on end of life care explains palliative care is provided if a patient has an illness which cannot be cured when the aim of the treatment is to make patients as comfortable as possible. End of life care is a form of palliative care a patient receives when they are close to the end of their life. Information on the NICE topic on palliative care explains, when deciding whether palliative care is appropriate, consideration should be given to estimate the patient’s prognosis. This is so appropriate adjustments can be made to providing care to patients in the terminal phase of their illness. It says people are likely to be in the terminal phase when they show certain signs including deteriorating day by day, or faster because of their underlying condition.
32. Mrs C had significant lung disease and was unwell during admission between 21 and 22 May. Our physician adviser explains generally it would be hard for clinicians to know when she would be nearing her end of life. The clinical records show Mrs C was getting back to her baseline condition (her condition prior to admission) and as we explain above, the test results throughout this admission show she was showing signs of improvement. From reviewing the evidence provided, there is nothing contained within the clinical records to show Mrs C was actively in the end of life stage prior to her discharge on 22 May. As the NICE topic explains, unless Mrs C had a deterioration in condition, it was not appropriate for her to receive end of life palliative care, or for the Trust to discharge her into a hospice setting. Our clinical advice supports this view.
33. Given there were no indications Mrs C was at the end of life stage, we have considered the Trust’s decision to discharge her back to her care home.
34. On 22 May, the Trust discharged Mrs C back into the care of her care home. The records show the Trust had a conversation with the care home on 21 May, who explained they would be happy to readmit Mrs C back into their setting, provided she was in the same position as she was prior to her hospital admission, and that she tested negative for COVID-19. The records show her condition returned to her baseline and she tested negative for COVID-19.
35. Taking this into consideration, we cannot be critical of the Trust’s decision to discharge Mrs C back to the original care setting on 22 May. The Trust had a conversation with the care home who confirmed it was happy to readmit Mrs C back to the setting if she was in the same position as she was prior to the hospital admission.
36. We consider the Trust acted appropriately in deciding to send Mrs C back to this care setting, and our clinical advice supports this view. We do not uphold this element of the complaint.
Physiotherapy 37. Miss K says the Trust failed to provide adequate physiotherapy care to her mother during these two admissions. She considers this caused her mother’s condition to deteriorate.
38. The BTS/ACPRC guidance explains patients with COPD will benefit from breathlessness management advice, including positioning and postures to lengthen the diaphragm. It outlines a variety of breathing techniques can be used to reduce shortness of breath and panic at rest and during exertion.
39. For ease of understanding we have split this into the two separate admissions:
21 – 22 May
40. We can see from the records the physiotherapy teams saw Mrs C the morning of 21 May, and twice on 22 May. The teams also contacted Mrs C’s care home to obtain her history.
41. On 21 May, Mrs C declined a mobility assessment. This is understandable as the Trust admitted her in the early hours of the morning. We can see the physio listened to her chest, however as she was very drowsy, she was not able to comply with any further chest physiotherapy or mobilisation.
42. On 22 May, the physiotherapy team returned in the morning to see Mrs C. The physio listened to her chest and noted ‘breath sounds throughout, no added sounds and strong dry cough’. Our physio adviser explains from this examination there was no indication for any further chest physiotherapy as there was no evidence Mrs C had any retained chest secretions.
43. When the physiotherapy team returned that afternoon, it completed an assessment of Mrs C. Her oxygen saturations had decreased when she was assisted to sit over the edge of the bed but returned to 92% with increased oxygen and reassurance. Mrs C was assisted to stand up to a frame, but she became lightheaded, nauseous and her blood pressure dropped. Mrs C was noted to be very short of breath at times, which was potentially caused by anxiety. The physio spent time with Mrs C to reassure her and show her breathing techniques to reduce breathlessness. Mrs C was made comfortable and stable in bed, and the physio team arranged to see her the following day, to plan to transfer her into a high-backed chair, however she was discharged before she was seen again.
44. From reviewing the physiotherapy treatment between 21 and 22 May, we can see the Trust has provided breathlessness advice, and the treatment plan before discharge included working on changing her posture by sitting her in a high-backed chair. This is in line with the BTS/ACPRC guidance on providing breathlessness management advice and reducing panic during exertion, and our clinical advice supports this view.
22 May – 25 May
45. We know the Trust did not provide Mrs C with any physiotherapy sessions during this admission.
46. We can see on 23 May, Mrs C’s oxygen saturation was desaturating to the low 80s (a normal oxygen saturation level is between 95 and 100%) and the Trust tried to improve this by increasing the oxygen prescription. The Trust decided to monitor the input and try to mobilise Mrs C after this. On 24 May, the Trust planned for the occupational and physiotherapy teams to assess Mrs C’s needs, however this was not done, as she sadly died early the next morning.
47. The clinical records show no evidence Mrs C had signs of retained chest secretions, and the Trust diagnosed her with pulmonary heart disease. Our physio adviser explains Mrs C was having difficulty maintaining oxygen saturation throughout this admission to a level in which attempting to mobilise her would even be appropriate. There is no reason to believe a physiotherapy assessment during this admission would have made any difference to Mrs C’s overall outcome.
48. Taking this advice and the evidence into consideration, we have found no failing in the Trust not providing any physiotherapy to Mrs C during the admission between 22 May and 25 May.
49. We consider there is no failing in the physiotherapy provided by the Trust, and we do not uphold this element of the complaint.
50. Overall, our decision is we do not uphold the complaint. We recognise how important Miss K’s complaint is to her and understand her reasons for bringing the complaint to us. We are sorry to hear of the continued impact this issue has on Miss K, and hope our findings provide Miss K with some reassurances over the care and treatment provided by the Trust to her mother towards the end of her life.