Mrs X’s discharge arrangements
15. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any signs that something has gone wrong.
16. Mr R says until he called the Trust and asked about the care put in place for Mrs X, no one knew nothing had been done. He says he had to call the care provider himself to make sure care was put in place. He believes without his involvement, nothing would have happened.
17. Department of Health guidance says discharge planning should start on the day of admission. It says clinicians should:
• identify if the patient has simple or complex discharge planning needs • co-ordinate the discharge planning process • identify an estimated discharge date • review the clinical management plan with the patient each day • take any necessary action and update progress towards the discharge or transfer date • involve patients and families so they can make informed choices that deliver a personalised care pathway and maximise their independence.
18. The MCA states it should be presumed that a person has capacity (the ability to make all or some decisions for themselves about their care and treatment) ‘unless it is proved otherwise’.
19. The Trust's complaint response explained Mrs X had improved on 26 February and it had done a therapy review. After this assessment, it explained Mrs X agreed to accept help at home. It explained the original discharge report was resubmitted to include a care package of four daytime calls with two night calls (this was an increase due to the level of help she needed) along with community physiotherapy.
20. The Trust’s response explained the concerns raised the day before discharge by Mr R had no impact on Mrs X’s care package, and the delay was in response to Mr R's concerns that Mrs X was not well enough to be discharged. It explained the doctor spoke to Mr R on the phone to confirm Mrs X's medically fit status and the discharge was postponed for 24 hours for these reasons.
21. The Trust also explained it had asked the Local Authority to comment on the care planned. It reported ‘care was agreed by the Local Authority to start [Mrs X's] package of care on Monday, 1 March 2021 at the tea call’.
22. We can see this was postponed until the tea call on 2 March 2021. Care was delivered at 4.26pm and 7.49pm. The waking night carer was with Mrs X from 10pm until 7am.
23. Our adviser explained the records suggest Mrs X was assessed during her admission, and it was identified she needed quite a large package of care. Planning for this began on 17 February and changed in line with Mrs X’s changing needs.
24. The records show the Trust noted Mrs X wanted to go home and she already had a social worker and care involvement at home.
25. The clinical team requested services on the 26 February 2021 with home care to start on 29 February (six calls per day). This was communicated with Mr R on 28 February when he raised concerns about the discharge decision. The doctor spoke with Mr R on the phone to confirm Mrs X was medically fit for discharge and her package of care was to start on 1 March. However, we can see this was rolled over to 2 March to make time for discussions with Mr R who expressed concerns.
26. In line with the MCA and Department of Health guidelines, the evidence shows appropriate care was planned and put in place for Mrs X before her discharge. It also shows Mrs X had capacity to be involved in and was kept involved in her discharge planning. We can see the Trust kept Mr R updated with changes in planning.
27. The evidence also shows the clinical team made necessary plans and Mrs X's package of care was updated throughout to facilitate her discharge. We can see Mrs X was seen by the medical team and was only discharged when they considered she was medically fit. The records show care took place at her home after discharge.
28. We recognise the discharge of Mrs X was difficult for Mr R. Our view is the correct discharge planning and package of care was given to Mrs X, and it appears the Trust’s actions were in line with the relevant guidelines. We hope our explanation gives Mr R some reassurance about what happened.
Lack of information sent home with Mrs X
29. Mr R says no discharge or medication notes were sent home with Mrs X when she was discharged. He says because of this, no notes could be found when the paramedics attended her home and this made her assessment more difficult and traumatic for her.
30. The Trust explained Mrs X was sent home with a copy of her take-home medications and discharge summary. The Trust said no further medical notes would normally be sent home with patients.
31. Our principles say all public bodies should follow their own policy and procedural guidance and any other rules governing the service they provide.
32. The NHS website guidance on ‘Being discharged from hospital’ states, ‘You'll also be given a letter for your GP, providing information about your treatment and future care needs. Give this letter to your GP as soon as possible. If you're given any medication to take home, you'll usually be given enough for the following 7 days. The letter to your GP will include information about your medication’.
33. DHSC hospital discharge and community support guidance says, ‘ensuring people have full information about the next steps of their care and be provided with a discharge summary which includes any changes to preadmission medication regime’.
34. We can see from the Trust’s response and records provided, a five-page detailed inpatient discharge summary was documented 1 March, which included a copy of the medication Mrs X was taking on discharge.
35. This also stated a copy would be sent electronically to her GP. We can also see the Trust’s website says, ‘When you go home your family doctor will be given details of your treatment and of any follow-up attention which you may need. It is important that you tell ward staff if you have changed your family doctor recently’.
36. We considered whether the discharge summary was provided and can see from the records it was created, the Trust nurse said it was provided, and the documents say it was sent to the GP. On balance, our view is the Trust gave Mrs X this information and gave a copy to the GP. We do not know why the paramedics could not locate this but can see the Trust appeared to follow its own policy and procedural guidance on patient discharge.
37. The Trust’s actions were also in line with our principles and the above DHSC and NHS guidance.
38. We have the highest sympathy with Mrs X’s situation and any difficulty she experienced. Our view is the Trust provided the necessary documentation to Mrs X on discharge, and it appears the Trust’s actions were in line with the relevant guidelines.
Staff not attending to Mrs X’s needs
39. Mr R says Mrs X was left to use a pad rather than being taken to the toilet. He says this was mainly due to a lack of staff on the ward.
40. In its complaint response, the Trust explained the care rounding sheets (charts completed identifying issues about patient needs and comfort) show one episode of urinary incontinence. It explained apart from this, Mrs X was continent of urine throughout her hospital stay.
41. The RCN guidance states:
Clinical indications for intermittent catheterisation (catheters are inserted several times a day, for just long enough to drain your bladder, and then removed), suprapubic catheterisation (a drainage tube is inserted into the bladder through a small cut in the abdominal wall), or urethral catheterisation (a drainage tube is inserted into the bladder via the urethra, and is either left in place or removed after the bladder is emptied)
• Acute urinary retention (AUR).
42. NICE guidance states:
A urinary frequency volume chart is used to help distinguish and diagnose the following:
a) Frequency – high frequency with normal 24-hour volume suggests that the bladder capacity is diminished (the bladder normally holds 300 – 600 ml urine comfortably)
43. The records show Trust staff documented Mrs X’s toileting needs in her toileting plan, showing she was often continent of urine and was also regularly taken to the toilet, used the commode or used a bedpan. We can also see an intermittent catheter was passed when Mrs X had problems with urinary retention on 26 February.
44. Our adviser explained the records show consideration was given to Mrs X’s toileting needs as staff did not rely on continence pads to manage her continence, as she was regularly taken to the toilet, commode or bedpan. They also explained Mrs X’s retention was noted and acted on in a timely manner and the decision of an intermittent catheter being passed was the usual method of addressing urinary retention.
45. The evidence therefore indicates the decision to catheterise Mrs X was appropriate and in line with NICE guidance.
Overall, the evidence shows the Trust did consider Mrs X’s toileting needs. It appears the Trust took the correct action and treated Mrs X in line with RCN and NICE guidance.
46. We recognise the experience of Mrs X’s toileting needs was distressing for Mr R. Our view is that good and appropriate care was provided to Mrs X by the Trust, and it appears the Trust acted in line with the relevant guidelines.