Gateshead Health NHS Foundation Trust

5. Mrs T complains about her mother, Mrs E’s inpatient stay at the Trust from 21 January to her discharge on 29 January 2021.

6. Mrs T specifically complains that:

• there was poor communication with her during Mrs E’s inpatient stay as well as during discharge • there were errors in protocols and medication at discharge • Mrs E’s DNACPR (do not attempt cardiopulmonary resuscitation) showed two different NHS numbers • she was unhappy at the outcomes following risk assessment to discharge Mrs E.

7. Mrs T says the whole process has been demanding and stressful. This has affected her own health and lifestyle as she had to give up her time to this complaint and as Mrs E continued to decline in health.

8. Mrs T says she wants the Trust to confirm improvements it has made or training it has given. She would like reassurance future patients will not go through this, and a written apology.

9. Mrs E was in her early nineties and had a history of multiple health conditions.

10. Mrs E was admitted as an inpatient to the Trust on 21 January 2021 due to worsening right sided heart failure. During the admission, staff changed Mrs E’s ramipril (medication to treat high blood pressure and heart failure) to 2.5mg twice daily, started ferrous fumarate to treat iron deficiency anaemia, started furosemide (medication to treat high blood pressure) and apixaban, and stopped warfarin (both used to treat and prevent blood clots).

11. When Mrs E moved wards, the Trust contacted a family friend and not Mrs T who was the next of kin, to tell her. Based on the information available at that time, Mrs E’s preference to return home, and the understanding with the team that the family were happy with this, a revised plan was made to discharge Mrs E home. Mrs E was discharged on 29 January.

12. Mrs T complained to us on 16 December 2021 and told us she was particularly concerned that the Trust had not improved its service in response to her complaint.

15. Mrs T says before Mrs E’s discharge from hospital, staff contacted a family friend instead of her. Mrs T says staff did not follow protocols during discharge and that medication at discharge was incorrect. Mrs T also says there were two NHS numbers on Mrs E’s DNACPR form, and she was unhappy at the outcomes after a risk assessment to discharge Mrs E.

16. In responding to the complaint and before Mrs E’s death, the Trust confirmed it had changed the next of kin details.

17. In response to us notifying the Trust we were investigating this complaint, it provided us with evidence it had made several improvements to its service to address the complaints Mrs T made. We have outlined these changes in the following paragraphs.

18. The Trust has updated its standard operating procedure in relation to discharge medicines service (DMS) which improves communication between primary and secondary care on discharge from hospital. It provides information about medication changes to reduce cases of avoidable harm caused by medicines.

19. The Trust has improved its communication with the prime team (who complete initial environmental visits once patients are home) and referrals are now received via a ‘nervecentre’ (IT system) to make sure patients’ needs will be met at discharge.

20. To make sure correct documents are being completed on discharge, there are now discharge co-ordinators on almost all wards, and part of their role is to make sure that transfer of care documents is completed before leaving the ward.

21. The Trust has introduced information governance training that staff must do to make sure they understand the importance of patient information. The Trust’s service line manager for medicine has spoken to the clinical skills team and they are looking to put this training on the induction for junior doctors. This will reduce any chance of future errors relating to discharge and DNACPR forms.

22. Our service model guidance states a resolution means delivering an answer or outcome for a complainant that resolves the complaint they have brought to us.

23. Our principles of good administration state public organisations should always deal with people fairly and with respect. They should be prepared to listen to their customers and avoid being defensive when things go wrong.

24. When mistakes happen, public organisations should accept them, apologise, explain what went wrong and put things right quickly and effectively.

25. Putting things right may include reviewing any decisions found to be incorrect and reviewing and amending any policies and procedures found to be ineffective, impractical or unfair, as well as giving appropriate notice before changing the rules.

26. Although the Trust provided us with evidence of improvements, it did not provide this to Mrs T after she complained, in line with our principles. If it had done so, Mrs T may not have felt the need to complain to us.

Conclusion

27. Before we decide if we should carry out a detailed investigation into a complaint, we look at whether the organisation got something wrong and what it has done to remedy the injustice claimed.

28. We have done this and from the evidence the Trust provided and from our telephone discussions with Mrs T, we have found the Trust has taken suitable steps to resolve this complaint to Mrs T’s satisfaction.

29. The Trust provided us with a copy of the standard operating procedures and evidence of the improvements and training being implemented. The Trust did agree for us to share this evidence with Mrs T. We shared this with Mrs T.

30. We spoke with Mrs T to go through this evidence and improvements in detail, to make sure the Trust had resolved the matter to her satisfaction.

31. During our call with Mrs T she confirmed she was now satisfied the Trust had learned from her complaint, had made improvements and was looking to implement training to prevent further errors, and it had apologised for her experience.

32. Mrs T told us she felt her complaint has been resolved and that she can now draw a line under it and move on.

33. As this complaint is now fully resolved, we will not be taking any further action.

1. We have carefully considered Mrs T’s complaint about the Gateshead Health NHS Foundation Trust (the Trust). We are sorry to hear about the circumstances that led Mrs T to come to us. We appreciate she has been through a difficult experience, given the circumstances of the complaint.

2. We have decided not to investigate this complaint further. This is because Mrs T wanted reassurances that the Trust has learned from her complaint, and the Trust has now provided these.

3. During our consideration we got evidence from the Trust that showed it had reflected on what Mrs T has said, improved its service, and apologised.

4. Having discussed this with Mrs T, we have agreed not to investigate this complaint further. This is because we have been able to provide Mrs T with the information and evidence she wanted and have therefore resolved this complaint.