Failure to refer to A&E
20. Before we decide if we should conduct 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 seen any signs something went wrong.
21. Mrs O told us Mr E fell at home in January 2021. When she found him, his breathing was heavy and he was unsteady on his feet. Mrs O told us King’s College Trust asked her to bring Mr E in for dialysis. She did so and asked the renal team (who diagnose and treat diseases of the kidney) to review her father.
22. Mrs O complains the dialysis unit sent him home, despite his poor health and knowing he lived on his own. She says King’s College Trust should have referred him to A&E and insisted he attend.
23. In its complaint response, King’s College Trust has said Mr E arrived at the dialysis unit at 6.30pm. King’s College Trust found his observations were satisfactory and consistent with a COVID-19 diagnosis.
24. King’s College Trust says a nurse completed an assessment. The nurse recommended that Mr E attend A&E, but he declined, so staff arranged an ambulance to take him home.
25. We will consider whether there are signs King’s College Trust’s decision to send Mr E home was not in line with relevant guidelines.
26. KQuIP guidance says, in paragraph 9.4: ‘Further action to be taken for SARS-Cov-2 (Covid-19) positive cases: Arrange frequent medical assessment to monitor clinical progress and arrange admission where needed.’
27. King’s College Trust says it was the clinical pathway at the time for the nursing team to assess patients testing positive for COVID-19. They would refer patients to A&E if they found any other issues needing assessment. This is explained in the KQuIP guidance.
28. The record says Mrs O told staff about Mr E’s fall at home. The record says Mr E told staff he did not have a fall but sat on the floor. The record says Mr E was often unsteady before and after dialysis. When staff suggested Mr E attend A&E, the record shows he ‘strongly refused’.
29. Our acute medicine adviser told us medical staff can recommend a course of action to a patient, but it is entirely up to the patient whether they follow it. Our acute medicine adviser said patients cannot be forced to follow advice or receive treatment without their consent.
30. Patients have the right not to follow advice when they are considered mentally capable of making such a decision. Our acute medicine adviser said there is no documentation to suggest Mr E was lacking mental capacity at the time.
31. The records indicate that a nurse at the King’s College Trust completed a medical assessment of Mr E and recommended another assessment at A&E.
32. We appreciate these events have been very distressing for Mrs O, especially as she believes King’s College Trust missed an opportunity to refer her father for treatment.
33. Considering the information above, there are signs King’s College Trust followed the relevant guidelines for assessing Mr E and recommending he attend A&E. We have seen no signs King’s College Trust should have insisted Mr E attend A&E. This concludes our consideration of this aspect of the complaint.
D&G Trust discharge
34. Mrs O told us D&G Trust should not have discharged Mr E the day after he was admitted as he was still very ill. We have explained in paragraph 20 what we consider before deciding to conduct a detailed investigation. Having done this, we have seen no signs something went wrong.
35. In its complaint response, D&G Trust said its staff assessed Mr E and found him to be clinically stable with no difficulty breathing. It said his oxygen concentrations were not below 92% at any stage (patients with oxygen saturation levels below 92% are thought to be at risk of respiratory failure).
36. D&G Trust said Mr E complained of abdominal pain and was unsteady on his feet. An abdominal ultrasound (technology that allows quick visualisation of the abdominal organs from outside the body) found an increase in the size of Mr E’s pre-existing AAA. D&G Trust said, after discussion with a specialist, its staff decided Mr E was not suitable for surgery.
37. D&G Trust said it completed blood tests and found the results were within acceptable limits. It said the investigations suggested Mr E had a COVID-19 infection.
38. We considered whether D&G Trust’s discharge of Mr E was within relevant guidelines.
39. GMC guidance paragraph 15 says doctors must:
‘a. adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b. promptly provide or arrange suitable advice, investigations or treatment where necessary c. refer a patient to another practitioner when this serves the patient’s needs.’
40. Our emergency medicine adviser told us doctors decide whether to discharge each patient from the emergency department (ED) individually. They said the decision is based on the doctor’s assessment, the results of investigations, the patient’s response to treatment in the ED and any other specialist assessments made while the patient is in the care of the ED.
41. The records show the ED doctor assessed Mr E clinically and arranged investigations (such as blood tests, an abdominal ultrasound and a chest X-ray). They then referred Mr E to the Integrated Discharge Team (IDT). The IDT’s role is to assess a person’s ability to manage daily tasks safely and to support their discharge or admission to hospital.
42. Our emergency medicine adviser told us the decision to discharge Mr E was based on the assessments by both the ED doctor and the IDT. Trust staff also considered the results of investigations and a period of observation in the ED for almost 12 hours. It appears this was in line with the GMC guidelines.
43. We appreciate how distressing this has been for Mrs O. We can understand why she concluded her father could not have been fit for discharge, given he was readmitted the following day.
44. We have seen no signs D&G Trust’s actions were not in line with the GMC guidelines. This concludes our consideration of this aspect of the complaint.
Failure to contact
45. Mrs O complains the Trust failed to contact her when her father’s condition deteriorated. We have explained what we consider before deciding to conduct a detailed investigation. Having done this, we have seen no sign something went wrong.
46. Mrs O told us a doctor from D&G Trust called her in late January at 11am to tell her Mr E was in a poor condition. She told us the doctor said if her father’s condition deteriorated, he would call again to let her know. She told us a doctor called again at 5pm that same day to say her father had died.
47. The Trust does not mention this aspect of the complaint in its response. Normally, we will only consider an issue if an organisation has received the complaint and provided a written response. But we have held the complaint for some time, and this part of the complaint is related to the treatment we have considered above.
48. We do not believe it would be appropriate at this stage to ask Mrs O to return to the Trust and ask it to reconsider the issue. We have decided to consider this matter now.
49. We have considered whether D&G Trust’s communication with Mrs O in late January was within relevant guidelines.
50. GMC confidentiality guidance says:
‘Sharing information with those close to the patient 34 You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support, while respecting the patient’s right to confidentiality.
Establishing what the patient wants 36 You should establish with the patient what information they want you to share, with whom and in what circumstances. This will be particularly important if the patient has fluctuating or diminished capacity or is likely to lose capacity, even temporarily. You should document the patient’s wishes in their records.’
51. Our acute medicine adviser said Trust staff knew Mr E was very ill but was still having active treatment in late January. The Trust had plans to increase his care to high-flow nasal oxygen after advice from the respiratory team.
52. The records do not show there was a phone call between the Trust and Mrs O at 11am. Records do show Mr E gave his consent to call Mrs O at 2pm. During the call, the Trust explained to Mrs O her father was very unwell and explained what the next steps in the clinical plan would be should his condition deteriorate.
53. The records at 2.50pm show a doctor spoke to a respiratory specialist to discuss Mr E’s treatment. Records show D&G Trust investigated Mr E’s symptoms and provided antibiotics and oxygen therapy for several days before his death.
54. Records show staff found Mr E unresponsive and declared him dead at 3.05pm. Staff attempted to call Mrs O at 3.10pm, but the call went to answer machine. The Trust was able to contact Mrs O at 4.24pm.
55. Our adviser said staff would not have expected Mr E to die at that time. Sadly, he died suddenly, making it impossible for the team to contact his daughter in time.
56. The medical records show doctors communicated with Mrs O in line with GMC confidentiality guidance. We can see doctors obtained consent from Mr E and informed Mrs O her father was very unwell.
57. We appreciate these events would have been very distressing for Mrs O and we are very sorry they happened. In our view, it seems there was no way for the Trust to conclude Mr E was likely to deteriorate or die suddenly. The Trust could not have warned Mrs O of this.
58. Given this, we have seen no signs the Trust did not act in line with the relevant guidance. This concludes our consideration of this aspect of the complaint.