Lancashire Teaching Hospitals NHS Foundation Trust

4. Miss B complains about the standard of care the Trust gave her father in March 2022. She says the Trust made a mistake by discharging Mr B back to his care home while he was still bleeding badly.

5. Miss B says her father had severe blood loss due to the Trust discharging him too soon and she believes he may still be alive if this situation had not happened.

6. Miss B also says the Trust caused her worry and distress by discharging her father when it did.

7. Miss B wants the Trust to accept that her father should not have been discharged and to apologise. Miss B also wants the Trust to reassure her that it will make service improvements to try to make sure the same thing does not happen to anyone else. She would also like a financial payment.

8. Mr B was in his eighties at the time. He had a diagnosis of vascular dementia (a common type of dementia caused by reduced blood flow to the brain) and was a permanent resident at a care home. Mr B was also doubly incontinent (when you cannot control your urine or faeces).

9. On the afternoon of 7 February 2022, staff at the care home noted he had quite heavy rectal bleeding (bleeding from the bottom) and called an ambulance. The paramedics took Mr B to the Trust’s emergency department (ED). Staff examined Mr B that evening and decided he was fit to be discharged in the morning.

10. The Trust discharged Mr B in the morning and he arrived at the care home by ambulance around an hour later. Less than an hour later, staff at the care home changed Mr B’s incontinence pad and noted he was still bleeding heavily. They contacted his GP and later called an ambulance. Mr B arrived back at the ED in the afternoon and Trust staff saw him immediately and referred him for admission.

11. Mr B stayed as an inpatient until 22 March and sadly died in May.

Mr B’s assessment

15. Miss B complains the Trust discharged her father back to his care home while he was still severely bleeding.

16. The Trust said after a full examination, staff diagnosed her father with a lower gastrointestinal bleed. The Trust decided to stop his recently prescribed apixaban (a medicine to help prevent blood clots) and discharged him as no further treatment was needed.

17. Mr B’s records show that he had significant rectal bleeding on 7 February 2022. The Trust did an abdominal and rectal examination and a blood test. The Trust considered the results as well as Mr B’s pulse, blood pressure and other vital signs. The Trust found Mr B had raised levels of urea in his blood. Urea is a nitrogen-containing waste substance that the kidneys clear from the blood and release into the urine.

18. Our A&E adviser said the presence of both fresh and clotted blood in what Mr B was passing, along with the raised levels of urea noted in his blood, should have alerted staff to an upper gastrointestinal bleed. The Trust should have followed NICE CG141 to treat this.

19. NICE CG141 says clinicians should use a Blatchford score to assess patients in the first instance. This score uses a number of biochemical and physiological tests to assess a patient’s risk and if they can be managed as an outpatient. A Blatchford score of above zero means a patient is at risk of needing more treatment.

20. Our A&E adviser calculated Mr B’s Blatchford score and said it would have been a minimum of three. This is due to the elevated urea result from his blood test. The score may have risen to a four if there had been melaena (blood in the stool caused by gastrointestinal bleeding) present, but this was unclear.

21. Our A&E adviser explained that deciding whether to treat patients with dementia when they present with acute medical problems is complex. In some circumstances it can be reasonable to decide not to treat a patient who has severe dementia. The records show the Trust did consider Mr B’s comorbidities (conditions other than the acute one he was presenting with) and decided it was not in his best interests to do more investigations.

22. Our A&E adviser said the Trust’s thinking that stopping the recently prescribed apixaban to prevent future bleeding was logical. But there is no evidence the Trust considered Mr B’s Blatchford score, which is used to assess the risk of more bleeding.

23. The Trust should have followed LGIB guidelines if it thought Mr B had a lower gastrointestinal bleed.

24. The LGIB guidelines say clinicians should use an Oakland score to assess the severity of a patient’s bleed. An Oakland score greater than eight indicates a patient has a ‘major bleed’ and is likely to benefit from hospital admission.

25. Our gastroenterology adviser calculated Mr B’s Oakland score and said it was over eight. There is no evidence in the records to show the Trust considered Mr B’s Oakland score when deciding whether to discharge him.

26. We cannot say the Trust’s decision to discharge Mr B was right. This is because the Trust did not act in line with NICE CG141 or the LGIB guidelines. We have found a failing in Mr B’s care.

27. We understand it is distressing when a family member is unwell, and anybody would want to make sure their loved one gets the most appropriate care. We are sorry to say this was not the case for Mr B.

Impact

28. Miss B says her father suffered from blood loss, which she believes the Trust could have stopped if it did not discharge him when it did. We are sorry to learn that Mr B’s bleeding did not stop after his first admission.

29. The Trust readmitted Mr B to A&E just under five hours after it discharged him. The Trust then began more investigations and did an endoscopy (a test to look inside the body using a thin tube and camera) and a CT scan (which uses X-ray and a computer to make detailed images of the inside of the body). The CT scan showed Mr B had signs of diverticular disease (inflammation of small bulges in the lining of the large intestine). Both tests showed no clear cause for Mr B’s bleeding.

30. Our gastroenterology adviser said this suggests Mr B’s bleeding was not caused by a reversible or stoppable source. Because of this, we cannot say Mr B’s blood loss was avoidable and it is likely he would have bled the same even if the Trust did not discharge him.

31. Miss B says she believes her father may still be alive had the Trust not discharged him when it did.

32. Our gastroenterology adviser said this period of illness likely would have shortened Mr B’s life. But we cannot say the Trust’s actions contributed towards this. This is because Mr B’s bleeding was sadly not reversible or stoppable.

33. Miss B says the Trust caused her worry and distress by discharging her father. We do not underestimate how concerning it must have been for Miss B to think her father was not getting the treatment he needed.

34. We have found a failing in the Trust’s decision to discharge Mr B. We can link this failing to the worry and distress Miss B felt.

Outcome

35. Part of the outcome Miss B wants is a financial payment.

36. Our Principles say to put things right, organisations should consider providing ‘financial compensation for direct or indirect financial loss, loss of opportunity, inconvenience, distress, or any combination of these’.

37. When deciding on a level of financial compensation, we use our severity of injustice scale to guide what we may ask an organisation to provide. Injustices that fall at level one on our scale are ones where the complainant has faced ‘annoyance, frustration, worry or inconvenience, typically arising from a single (one-off) incidence of maladministration [fault] or service failure, where the effect on the individual is of short duration, and where there are no other adverse effects or ongoing wider impact’. Injustice of this type is likely to last for up to two weeks.

38. The Trust made the decision to discharge Mr B at around 1.20am on 8 March. The Trust then discharged Mr B at around 8.30am and readmitted him at 1.17pm the same day. We are in no doubt that Miss B’s concern for her father’s condition went beyond this period. But this is the only time we can say the Trust’s failing was responsible for Miss B’s worry and distress.

39. The maximum length of the impact on Miss B that we can put down to the Trust’s failing is around 12 hours (based on the period above). We recognise she may have had some ongoing concerns. This means we would place Miss B’s injustice at level one on our scale.

40. When an injustice falls into level one, we do not think a financial payment is appropriate. We are not recommending for the Trust to make a financial payment to Miss B.

41. The other outcomes Miss B wants are for the Trust to accept its mistake and apologise for it. Miss B also wants the Trust to make service improvements to try to make sure the same thing does not happen to anyone else. We considered these outcomes below.

1. We have carefully considered Miss B’s complaint about Lancashire Teaching Hospitals NHS Foundation Trust’s (the Trust) decision to discharge her father, Mr B. We understand how difficult and worrying it is when a family member is unwell. We are very sorry to learn of Mr B’s death.

2. We have found a failing in the Trust’s decision to discharge Mr B. The Trust did not complete the severity assessment needed for Mr B’s condition. We have not been able to link this failing to the impact Miss B says her father experienced. We have been able to link this failing to the worry and distress Miss B experienced. We partly uphold the complaint.

3. We recommend the Trust apologises to Miss B and creates an action plan to help reduce the risk of another patient having a similar experience.

42. Our Principles say to put things right, organisations should consider providing ‘an apology, explanation, and an acknowledgement of responsibility’ as well as ‘remedial action, which may include reviewing or changing a decision on the service given to an individual complainant; revising published material; revising procedures, policies or guidance to prevent the same thing happening again; training or supervising staff; or any combination of these’.

43. We recommend the Trust accepts it did not appropriately discharge Mr B and apologises to Miss B for this. The apology should recognise the worry and distress the decision caused Miss B. The Trust should share this with Miss B and us within one calendar month of the date of our final report.

44. We also recommend the Trust creates an action plan to set out how it will reduce the risk of a similar thing happening with another patient. The Trust should share this with Miss B and us within three calendar months of the date of our final report.