Fitness for discharge
26. Discharge guidance sets out a number of points for clinical staff to consider to reach a decision on if a patient is fit for discharged. It says clinician staff should consider if the patient: • needs high dependency care, oxygen therapy, IV fluids or IV medication or regular observations (NEWS above three). A NEWS (national early warning score) is a set of observations that are scored. A higher score shows the need for increased monitoring and a potential serious decline in health • has a reduced level of consciousness or acute functional impairment that could not be met with social care (acute functional impairment may be a physical or neurological condition or illness that prevents a patient from doing day to day activities) • is in the last hours of life • has had recent lower limb or abdominal surgery or had an invasive procedure with a risk of life-threatening deterioration.
27. The guidance says if a patient does not meet any of these criteria, then clinicians should consider discharge.
28. Mrs C says the Trust wrongly discharged her father when he was clinically dehydrated and could not move. We have looked more closely at Mr J’s records to decide if the Trust properly assessed and treated Mr J’s levels of hydration and mobility before it considered his fitness for discharge.
Hydration
29. Dehydration happens when the body loses more fluid than it can take in. NICE guidance explains how to assess if a patient is dehydrated and when to give fluid intervention (IV fluids). If Mr J had been having IV fluids, he could not have been discharged.
30. The guidance says clinical examination should include an assessment of the patient's fluid status, including their pulse, low or high blood pressure, capillary refill and fluid retention (swelling). It explains this can be monitored through NEWS, fluid balance charts and weight recording. The guidance also suggests laboratory investigations including a full blood count.
31. Records show the Trust examined Mr J on admission and took his blood pressure, pulse, capillary refill and blood tests including a full blood count and kidney function. His blood pressure was 127/79, pulse was 89 and his respiratory rate was recorded as 18. These were all within normal ranges.
32. The Trust weighed Mr J and it completed daily food charts which showed he was eating and drinking at mealtimes. Nursing notes from 1 to 9 of January 2022 say he was eating and drinking independently.
33. There are limited monitoring observations. Clinical notes from 31 December 2021 show Mr J needed hydration, and on 6 January 2022 the doctor recorded the lining of Mr J’s mouth was dehydrated. There are also several references to oedema (swelling caused by fluid retention) and a swelling in his left lower limb.
34. Observations recorded on 4, 5, 6, 8 and 9 January 2022 show Mr J’s heart rate and blood pressure stayed within normal ranges. His swelling was found to be linked to his unconfirmed cancer diagnosis.
35. We asked our adviser if these were signs of clinical dehydration showing a need for IV fluids. They confirmed in their experience there was no need to give IV fluids to Mr J.
36. The Trust did not complete fluid balance charts. It said this is because Mr J was eating and drinking independently, so they were not needed.
37. GMC guidance says doctors must assess a patient’s condition properly. We also asked our adviser if fluid charts were needed to assess and treat Mr J.
38. Our adviser explained a fluid balance chart is not needed for every patient. They said in their experience they are only needed when patients are significantly dehydrated or known to not be drinking well.
39. Taking this information into account we can see the Trust did the right sort of assessments of Mr J’s hydration levels throughout his admission. This was in line with NICE and GMC guidance.
40. Some assessments showed signs of dehydration and there was not always the frequency of assessments we would expect to see. But we are satisfied there is enough information to show a picture of Mr J’s condition. Based on this, we are satisfied he did not have a clinical need for IV fluids before his discharge.
41. We recognise on readmission this had changed and the Trust gave IV fluids almost immediately. We also listened to the condition Mrs C described Mr J being in on transfer to the car and at home. Mrs C told us she spoke to a matron who said she should have wheeled Mr J straight back to A&E.
42. Given this conversation and the fact there were only around 20 hours between Mr J’s discharge and his readmission, we appreciate and understand Mrs C’s concerns.
43. We looked at the symptoms which led to the Trust giving IV fluid on readmission. They included an increased respiratory rate of 32, blood pressure of 112/59 (hypotension or low blood pressure) and a high heart rate of 126.
44. These results were a significant change from the last observations taken at 2.40pm after Mr J’s fall and shortly before his discharge. At that time, Mr J had a respiratory rate of 18, blood pressure of 148/79 and heart rate of 84.
45. We are very sorry to see how Mr J deteriorated after his discharge. Taking account of all the evidence we can see Mr J declined greatly and this appeared to happen quickly. When we look at the information available to the Trust at the time of discharge, this does not change our view on the Trust’s assessment of Mr J’s hydration needs.
Mobility
46. Mrs C says her father could not move into the car and the family had to physically lift him. She also explained when he arrived home he could not move from the chair and had to urinate into a bottle and sleep in a chair overnight. We can appreciate how difficult this must have been for them.
47. The Trust said the consultant and the therapy team reviewed Mr J before his discharge and they noted no concerns about his mobility. It also explained Mr J walked to the wheelchair on the ward when he was being discharged, and there were no concerns Mr J could not go to the toilet independently at home.
48. Discharge guidance says an acute functional impairment may suggest a patient is not ready for discharge.
49. An support worker saw Mr J on 4, 7 and 8 January 2022. The first time they found him to be mobile without assistance and independent with activities of daily living (this description includes activities likes eating, washing, dressing).
50. On the second visit they recorded that he was mobilising independently around the bed area. On 8 January after his fall, they saw he was moving independently without help.
51. On 9 January before his discharge, a physiotherapist and an occupational therapist reviewed Mr J. They recorded he was independently mobile and steady walking, and he did not have any therapy needs.
52. The records show regular assessment of Mr J before and after his fall with no signs of an acute functional impairment. There is no evidence in the records that shows his discharge was not in line with the discharge guidance.
53. We recognise there is a clear difference between Mrs C’s account of her father after discharge and the Trust’s assessment hours earlier. We do not question the accuracy of Mrs C’s account. Unfortunately, we cannot say why Mr J’s condition was so different.
54. We cannot see the Trust was aware of this difference at the time. Had the Trust known of the difficulties the family faced transferring Mr J to the car, this would have prompted further assessment.
55. In its complaint response the Trust said a more experienced member of staff could have identified Mr J’s deterioration if they helped him to the car. We recognise this supports Mrs C’s view that the Trust did not do enough.
56. We use guidance to help us decide if what went wrong falls so far below the expected standard to mean it was a failing.
57. In this case there is no guidance that says a more experienced member of staff should help a patient when they have been discharged. For this reason, we cannot go as far as to say there was a failing in the Trust’s actions.
58. We realise if the Trust had done what it said, this could have a made a difference to its decision to discharge Mr J at that time. We appreciate this is difficult for the family to know, as it may have helped avoid the distress of the next hours.
Conclusions
59. Mr J’s records show the Trust assessed his hydration levels and mobility in line with guidance. They did not show a need for IV fluids or an acute level of functional impairment.
60. When we consider the records and the information available to the Trust at the time of discharge, the Trust’s decision was in line with the relevant guidance. For this reason, we have seen no failings in this part of the complaint.
61. We are very sorry to hear of Mrs C’s experience and recognise the lasting impact those hours had on her, her father and the family. We realise this was not the outcome she was hoping for, particularly given the Trust’s response. We hope she is reassured by the thorough consideration we have given to the records and her experience.
Communication on discharge
62. Mrs C complains the Trust did not communicate her father’s clinical condition to the family, either verbally or in a written discharge summary. She says he was handed over to them in a wheelchair by a student nurse who did not have the ability to assess him.
63. Discharge guidance says the individual and their family should be given relevant information about the discharge. NMC guidance also says nurses should keep clear and accurate records, check people’s understanding and communicate effectively.
64. There is a document in Mr J’s records called nursing assessments and care planning. Pages 37 and 38 contain a discharge checklist. This includes a section confirming staff have discussed the discharge with the patient and their family, they have fully explained medication needs and wound care and any pressure-relieving equipment had been discussed and ordered. The Trust did not complete this document. There is no explanation for this.
65. Nursing notes show Mr J had blanching skin (when the skin goes white because of restricted blood flow) on arrival. By 3 January 2022 he had developed a moisture lesion. This was still there on 6 January but not recorded in the days after.
66. On 8 January ward staff contacted his Mrs J by phone to discuss Mr J’s discharge and then again on 9 January when it was rearranged after his fall. There is no evidence in these notes to show ward staff discussed Mr J’s medication or pressure needs.
67. The Trust told us ward staff are confident Mr J’s discharge letter was in his medication bag and it included the relevant information.
68. We cannot confirm this as the family did not get the letter. We also note the discharge letter on record did not include information about the moisture lesion and it also included confidential information about his unconfirmed cancer diagnosis that Mr J had asked the Trust not to share.
69. For these reasons, it is our view the Trust did not act in line with the discharge guidance and NMC guidance. This is because it did not complete the relevant paperwork to show it fully communicated Mr J’s discharge needs to him or his family. As Mrs C and the family did not get this information, this was a failing.
Impact of this failing
70. Mrs C says the poor communication meant the family were unaware of her father’s needs, his overall frailty or of the moisture lesion he had developed.
71. She says because of this the family could not give Mr J appropriate care or advise emergency staff accurately on his condition. She says this was both distressing and embarrassing for them all.
72. Mrs C told us about the shock and upset caused when Mr J suddenly died and realised that his last hours at home had been spent in such an uncomfortable and undignified way. She explains this had had a lasting effect on the family.
73. Mrs C also explained the embarrassment for the whole family at being unable to clearly communicate his needs and condition to emergency staff the next day.
74. We can see the family were confused and upset by Mr J’s condition. We recognise this increased as they did not understand his needs. Had the Trust clearly communicated Mr J’s needs, it is likely the family could have supported him better and this would have significantly reduced this distressing time for him and the family.
75. Records show when Mr J was readmitted the Trust documented his moisture lesion as grade two. This is where there is skin loss and blistering. We recognise the progression of this wound would have been painful for him. We also appreciate it would have been difficult for the family to witness and to find this out from emergency staff.
76. As part of its complaint investigation the Trust apologised about the way it handed over Mr J’s information. It also explained it has since discussed the handover with the staff involved.
77. The Trust repeated to us that it had spoken at length to the member of staff involved who has reflected on their actions.
78. We recognise the Trust has taken some steps to address the failings we have found. We have seen failings in the Trust’s documentation as well its communication with the family. Our findings go further than the issues the Trust recognised during its own investigation.
79. It is not clear to us that the Trust has recognised the full impact of the failings we have seen, or explored this with all the staff who may have been responsible for completing the paperwork. We have made recommendations about what the Trust should do to put this right below.