Mid and South Essex NHS Foundation Trust

2. Mrs O complains about the care and treatment, and failed discharge, of Mr M from the Trust between 7 and 23 April 2020. Specifically, she complains: • the Trust put a DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) in place without telling her on 7 April • Mr M should not have been discharged on 23 April. He was also discharged without all his medication, tablets were missing, and some medications were issued without labels.

3. Mrs O believes these issues led to Mr M’ death. She explains his mixed dementia was partly vascular and due to ill health. After his discharge, he went to a care home for two months as he could not cope or care for his wife. Mrs O says she was shocked no one told her about the DNACPR, as she had Power of Attorney. She says she had to explain the form to her mother, and this was very upsetting for her. Mrs O says she could not contact the hospital, and Mr M could not take his medication.

4. Mrs O would like the Trust for an explanation and to apologise. She would like it to make service improvements and train hospital and pharmacy staff. Mrs O would also like some compensation for the way the Trust looked after Mr M.

5. On 7 April 2020, Mr M went to the Trust with binary sepsis (a life-threatening reaction to an infection), secondary to a stone in the main bile duct (a tube that carries bile from the liver and the gallbladder through the pancreas and into the upper part of the small intestine) and an acute kidney injury (where your kidneys suddenly stop working properly). An ST3 (specialist training doctor) signed a DNACPR form.

6. On 8 April Mr M was moved to a COVID-19 ward. Mrs O could not visit because of COVID-19 restrictions.

7. The Trust discharged Mr M on 23 April with a course of antibiotics to complete, a planned follow-up, and an increased care package.

8. On 24 April Mr M was readmitted to the Trust as he was feeling unwell and having difficulty managing at home. The Trust treated him with more antibiotics for a urinary tract infection (UTI. These infections affect the urinary tract, including the bladder, urethra, or kidneys).

9. On 28 April Mr M was discharged to a nursing home for respite care.

10. On 13 June Mr M sadly died.

DNACPR

14. We first looked at Mrs O’s concerns a DNACPR was put in place without telling her.

15. We can see from Mr M’s records a doctor assessed him when he was admitted. His health records include a DNACPR form dated 7 April 2020. The form says CPR is unlikely to be successful because of Mr M’s frailty, dementia, and other health issues. It states this was discussed with Mr M who agreed. The form was approved by a consultant on 14 April.

16. The BMA, Resuscitation Council (UK) and RCP guidance says patients do not have to give consent for a DNACPR, but doctors should tell the family.

17. We understand the upset this caused Mrs O and her mother. The Trust has accepted this and apologised to Mrs O. It explained the doctor could not discuss DNACPR with Mr M’s family at the time because of COVID-19 visiting restrictions.

18. The Trust’s apology and explanation is in line with our Principles for Remedy, putting things right. These say, ‘where maladministration or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise’.

19. We consider the Trust has done enough to put this right and we are not asking it to take any other action.

Hospital Discharge

20. We next considered whether the Trust discharged Mr M properly on 23 April.

21. We took clinical advice to help us understand the circumstances.

22. There are two aspects of hospital discharge, medical and physical fitness and community support.

23. Records show a junior doctor saw Mr M on 22 April. His blood results were normal and NEWS score (NEWS is a monitoring tool used to measure the illness of a patient) was back to baseline level (an initial measurement of a condition that is taken early and used for comparison over time to look for changes). Mr M’s last measurement was early in the morning of 23 April, the day of his discharge. This records a normal score of zero, which shows he was not unfit or unwell and no concerns were recorded at this time. Therefore, Mr M was medically fit for discharge.

24. Records show the rehabilitation team saw Mr M regularly. He was seen by the team on 22 and 23 April. Mr M was discharged from hospital with an increased package of care with the maximum of two carers to visit four times a day.

25. After Mr M’s discharge, he unfortunately became unwell and was readmitted the next day. Our adviser said Mr M’s discharge was in line with the Department of Health guidance, which says: • Discharge and transfer planning starts early to anticipate problems, put appropriate support in place and agree an expected discharge date.

• A person-centred approach treats individuals with dignity and respect and meets their diverse or unique needs to secure the best outcomes possible.

• The MDT (Multi-Disciplinary Team) works collaboratively to plan care, agree who is responsible for specific actions and make decisions on the process and timing of discharges and transfers.

26. This is what the Trust did. We have not seen that the Trust did anything wrong regarding Mr M’s discharge from the hospital.

Medication

27. Mrs O is concerned Mr M was discharged without all his medication, tablets were missing, and some medication was issued without labels.

28. The Trust apologised it discharged Mr M with unlabelled/unpackaged medication and for the distress this caused. The Trust assured Mrs O it shared her concern with the ward team to avoid this happening again in the future. It explained this is not normal practice and this was an unfortunate oversight. The Trust said it made staff aware of this incident and efforts have been made to improve practice where possible. It explained normally extra medications should not be given to the patient on discharge but returned to the pharmacy. It apologised this was not the case with Mr M, and these were sent home with him.

29. This is not in line with NICE guidance on effective use of medicines, which says:

‘1.2 Medicine related communication systems when patients move from one care setting to another says, Relevant information about medicines should be shared with patients, and their family members or carers, where appropriate, and between health and social care practitioners when a person moves from one care setting to another, to support high quality care. This includes transfers within an organisation – for example, when a person moves from intensive care to a hospital ward – or from one organisation to another – for example, when a person is admitted to hospital, or discharged from hospital to their home or other location.

1.2.3 details of the medicines the person is currently taking (including prescribed, over-the-counter and complementary medicines) – name, strength, form, dose, timing, frequency and duration, how the medicines are taken and what they are being taken for.

1.2.4 Health and social care practitioners should discuss relevant information about medicines with the person, and their family members or carers where appropriate, at the time of transfer. They should give the person, and their family members or carers where appropriate, a complete and accurate list of their medicines in a format that is suitable for them. This should include all current medicines and any changes to medicines made during their stay’.

30. We understand the inconvenience and upset caused to Mr M and Mrs O. The Trust realised it did not follow its own practice, apologised and has taken steps to stop the same issue happening again. This is in line with the our Principles for Remedy which say:

‘where maladministration or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise. If that is not possible, the remedy should compensate them appropriately. Remedies should also be offered, where appropriate, to others who have suffered injustice or hardship as a result of the same maladministration or poor service.

There are no automatic or routine remedies for injustice or hardship resulting from maladministration or poor service. Remedies may be financial or non-financial. An appropriate range of remedies will include: • an apology, explanation, and acknowledgement of responsibility • remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures to prevent the same thing happening again; training or supervising staff; or any combination of these’

31. We consider an acknowledgement, explanation, apology, and efforts to improve its procedure from the Trust is appropriate and we are not asking the Trust to do anything more.

32. We understand Mrs O’s distress, and it is clear she is concerned about Mr M’s care. We do not wish to dismiss the impact she says this experience had on her, Mr M, and the family. We have seen no indication the Trust did anything wrong when deciding to discharge Mr M. The Trust has apologised for the medication error and taken steps to improve its service. It apologised it could not discuss Mr M’s DNACPR. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for this.

1. We have carefully considered Mrs O’s complaint about Mid and South Essex NHS Foundation Trust (the Trust). We are sorry to hear about her concerns and recognise the effect these have had on her and her family. We have decided not to consider the complaint further. This is because we consider the Trust has already done enough to put right the impact of not checking Mrs O’s father’s, Mr M’s, medication before he was discharged. We did not see indications of failings with the other parts of her complaint.