Barnsley Hospital NHS Foundation Trust

4. Mr L complains about the care and treatment his mother, Mrs L, received from the Trust between 13 April and 11 May 2023. Specifically, Mr L complains: • On 20 April, the Trust incorrectly deemed his mother as MFFD • the Trust did not put a care package in place following Mrs L’s discharge on 11 May, despite it agreeing to this before her discharge and the discharge to assess at home assessors stating she required a care package • the Trust discharged Mrs L on 11 May without catheter care and support.

5. As a result of the Trust discharging his mother too soon, Mr L says she needed a further admission two days later with similar symptoms, which caused distress. He explains the lack of care package meant his mother was without care for four days before the family could reinstate her previous private care arrangement. In turn, this meant his elderly father had to care for her, without support. This left them exposed and vulnerable. Mr L told us this stress and anxiety then affected his father’s health.

6. As a result of the Trust not arranging catheter care, Mr L said his sister had to change his mother’s catheter in the evenings for the four days. This caused her stress and inconvenience, due to the additional cost and time involved.

7. Mr L said as a result of these events, Mrs L’s condition further deteriorated leading to another admission to Hospital on 29 May 2023, and her having to live in a care home, sooner than she should have. The experience has caused upset and distress to the whole family.

8. Mrs L was 91 years old at the time of events and has dementia.

9. On 13 April 2023, an ambulance transported Mrs L to the Trust’s emergency department (ED) as she had become increasingly lethargic, had decreased mobility, and was unwell with limited responsiveness following testing positive for COVID-19 in February. The Trust admitted Mrs L to its Acute Medical Unit. Clinicians thought Mrs L had community acquired pneumonia. The Trust treated Mrs L for a lower respiratory tract (the trachea and lungs) infection and urine infection throughout her admission.

10. On 20 April, the Trust discharged Mrs L with a plan to discharge to assess in the community. The Trust’s website explains under the discharge to assess process, local care services will be involved in assessing someone’s care needs once they have returned home.

11. Mr L said his family disagreed with this pathway as the family and the Trust had not agreed a resourced care plan in place prior to her discharge. He told us the family viewed this as a serious danger to Mrs L as the Trust would not address any potential issues or need for assistance until she was at home. Mr L also explained his mother’s mobility was impaired and the only person to care for at home was his 91 year old father. He explained to avoid this, the family arranged a two week respite care placement at a local residential home, however a few days later Mrs L had to return to the Trust’s ED.

12. On 23 April, Mrs L attended the Trust’s ED again as she experienced multiple episodes of diarrhoea, decreased oral intake and was less responsive than normal. The Trust treated Mrs L for cellulitis (a skin infection) and diarrhoea.

13. On 11 May, the Trust discharged Mrs L with a plan to discharge to assess in the community, which happened at home later the same afternoon. Mrs L already had a care package in place before her hospital admissions, so the family were able to extend this at short notice, but not until four days after her discharge.

14. Mrs L attended the Trust’s ED again on 29 May with a urinary infection and was discharged on 15 June to a care home. She has resided there ever since. Mr L told us a social services assessment concluded Mrs L to be unfit to return home due to the level of care she requires.

20 April discharge

19. The Trust admitted Mrs L on 13 April with lethargy and reduced mobility. The records also indicate she had a recent COVID-19 infection. During her admission, doctors diagnosed her with deep vein thrombosis (DVT - a blood clot in a vein) and treated her with anticoagulation (medicine to help prevent blood clots).

20. Mr L complains the Trust incorrectly deemed his mother as fit for discharge home on 20 April. He is concerned the decision was incorrect as she presented to the Trust’s ED again within 48 hours of her discharge due to concerns over possible infection in her lower leg, clostridium difficile (C.Diff – a type of bacteria that can cause diarrhoea) and sepsis.

21. The Trust said following clinical review on 20 April, staff concluded Mrs L was clinically stable and as she had been so for several days, and was not requiring immediate or urgent intervention, it could discharge her with a discharge to assess. It said a doctor reviewed Mrs L again at 1pm on 20 April and noted she was comfortable, stable and the doctor had no new concerns. It noted Mrs L’s leg was swollen but said there was no requirement for immediate intervention and as she remained clinically stable with appropriate follow ups arranged, it could discharge her from hospital.

22. The records evidence staff carried out regular assessments of Mrs L during her admission. From the physician advice we understand Mrs L’s DVT did not cause further concern throughout her admission, and staff provided appropriate treatment for it. These actions show staff were aware of Mrs L’s condition and were therefore in line with GMC’s ‘Good Medical Practice’. This says doctors must adequately assess the patient’s conditions, taking account of their history including the symptoms, psychological, spiritual, social, cultural factors, views, values and where necessary examine the patient.

23. The Trust deemed Mrs L MFFD on 20 April and discharged her the following day. As such, we have reviewed Mrs L’s clinical notes, NEWS (national early warning score) charts and pathology reports leading up to her discharge.

24. NEWS is a tool developed by the Royal College of Physicians (RCOP) which improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes. The NEWS is based on an aggregate scoring system in which a score is allocated to physiological measurements. These are respiration rate, oxygen saturation, blood pressure, pulse rate, level of consciousness or new confusion, and temperature.

25. The RCOP classifies an aggregate NEWS score between zero and four as low clinical risk, requiring a ward based response. A red score, a score of three in any individual physiological measurement, is a low to medium clinical risk requiring an urgent ward based response. An aggregate score of five or six is a medium clinical risk which requires an urgent response by a clinician or team with competence in the assessment and treatment of acutely ill patients. An aggregate score of seven or more is high clinical risk which requires and urgent or emergency response.

26. On 19 April at 1.10pm, the doctor noted Mrs L had a NEWS of one, indicating low clinical risk. They noted she had no chest pain, no difficulty breathing, her chest was clear, her abdomen was soft and non tender. Therefore, they considered she was MFFD.

27. On 20 April at 10.24am, the records show Mrs L’s NEWS score was four due to an episode of low blood pressure, which indicates low to medium clinical risk. At 11.44am, the records show Mrs L’s NEWS score was zero, indicating low clinical risk.

28. At 1pm the doctor noted ‘DVT left leg, patient is comfortable, no fresh concern, vitals (the bodies important internal organs) stable, chest clear, abdomen soft, non tender, left leg – swollen mild tender, no pain on passive stretch & toes, active knee, ankle + toe movements present. Plan, MFFD…’. The records show Mrs L’s NEWS score remained as zero for the rest of the evening.

29. On 21 April at 10.26am and 11.20am the records show Mrs L’s NEWS score was three due to low blood pressure. The ward round proforma states the plan was to ‘monitor vitals/BP [blood pressure] in an hour – if no concerns then MFFD’. The timing of this ward round is unclear. At 12.47pm the records show Mrs L’s NEWS score was zero.

30. Throughout her admission, Mrs L had intermittent NEWS scores (between one and four) due to low blood pressure. Specifically on 17, 19, 20 and 21 April. When this happened, staff increased the frequency of her observations and measured her score again.

31. Our physician adviser explained Mrs L’s NEWS scores do not indicate she was deteriorating. The records show Mrs L’s blood pressure changed occasionally, but as highlighted above, this did not remain significantly abnormal for any length of time and did not seem to be worsening progressively.

32. From the physician advice we understand Mrs L’s white blood cell count remained normal throughout this admission. A low white blood cell count usually means the body is not making enough white blood cells, increasing risk of getting infections.

33. The records show her c-reactive protein (CRP) was 113 and on 18 April, her CRP was 82. CRP is a marker of inflammation in the blood, and it rises within hours of the inflammatory stimulus. Our physician adviser explained with Mrs L’s clinical stability improving and an improving CRP, it is not necessary for clinical staff to keep checking this, as there had been no clinical change. This is in line with GMC ‘Good Medical Practice’ which states doctors must adequately assess the patient’s conditions, taking account of their history.

34. Therefore, we have not seen evidence Mrs L was deteriorating at the time of her discharge. Her observation charts, clinical notes and pathology reports indicate she was MFFD.

35. This is in line with the Trust’s ‘Admission, discharge and transfer’ policy which states the Trust should discharge patients when they clinically stable and fit for discharge.

36. On this basis, we have not seen any evidence indicating something went seriously wrong here and so we will not consider it further. We hope this provides Mr L some reassurance regarding his mother’s condition.

11 May discharge

37. Mr L complains the Trust did not put in place a care package following Mrs L’s discharge on 11 May, despite it agreeing to this before her discharge and the at home assessment stating she required a care package.

38. Mr L said the staff conducting the assessment following Mrs L’s discharge, on 11 May, identified she required a number of support aids and a care package. He said the staff were not able to resource a care package. Mr L explained this left his elderly father to meet his mother’s care needs alone and without the support of any professionally trained staff. He told us this was exactly the scenario the family feared throughout the discharge process. He said the alternatives staff offered were for Mrs L to return to hospital, or for the family to arrange a care package with a private provider.

39. Mrs L’s family were able to extend her previous care package to meet her requirements, but only four days after her discharge. As such, Mr L said this meant his mother was without additional care for four days.

40. The Trust explained Mrs L was suitable for discharge with a discharge to assess in the community. It said staff should not have promised that a support package would definitely be in place and the correct information that staff should have provided is that Mrs L's care package would need reinstating after the discharge assessment and that this may identify areas where other support needs are identified.

41. Department of Health and Social Care, ‘Hospital discharge and community support guidance’, updated 1 July 2022, details the discharge to assess model. It says ‘The discharge to assess model is built on evidence that the most effective way to support people is to ensure they are discharged safely when they are clinically ready, with timely and appropriate recovery support if needed. An assessment of longer-term or end of life care needs should take place once they have reached a point of recovery, where it is possible to make an accurate assessment of their longer-term needs.’

42. Pathway one of the discharge to assess model says ‘Likely to be minimum of 45% of people discharged: able to return home with new, additional or a restarted package of support from health and/or social care. This includes people requiring intensive support or 24-hour care at home. Every effort should be made to follow home first principles, allowing people to recover, reable, rehabilitate or die in their own home.’

43. On 28 April, the physiotherapist had a discussion with Mrs L’s daughter, who raised concern about Mrs L returning home as her family felt it would be unsafe. Mrs L’s daughter was also worried Mrs L’s husband would be her main carer until the morning.

44. On 2 May, the doctor noted a plan that if Mrs L’s electrolytes (minerals that carry an electric charge and are vital to specific processes for bodily function) were normal then she was MFFD. On 3 May, the notes state Mrs L is going to a discharge to assess bed (a bed in a care home, community hospital or other bed-based rehabilitation facility).

45. On 3 May, the notes indicate Mrs L’s family were waiting for a discharge to assess bed for her. The discharge team’s notes indicate the plan was to aim for discharge on 4 May.

46. On 10 May, the therapist discussed Mrs L’s discharge with Mr L and her daughter in law. This states ‘…patient will require D2A (discharge to assess) for assessment in own environment and struggling to manage patient at home’. The notes also state ‘Discussed with son happy for D2A for assessment in own environment. Ward to liaise with son regarding discharge home’.

47. On 11 May, the Trust discharged Mrs L to her home with a discharge to assess in place. Following this, an occupational therapist assessed Mrs L at home on the same day. Whilst it was not the Trust who conducted the discharge to assess assessment, it was able to provide us with the records of the assessment. This has helped us to understand what the outcome of the assessment was and whether the occupational therapist requested further input or support from the Trust for Mrs L.

48. The assessment indicated Mrs L required a bed lever to help her mobilising out of bed, a wheeled commode, a swivel bather to help mobilising in an out the bath, possibly a bath step, a referral for a falls and bed sensor and community physiotherapy to improve her mobilising out of bed.

49. The assessment noted Mrs L had a private care package in place with one morning call to support with her morning routine and she lived with her husband who was struggling with his own health needs including hernias which limited his ability to provide support. The occupational therapist noted Mrs L’s daughter’s concerns about Mr L’s memory, food safety and ability to prepare healthy meals. The occupational therapist advised an additional support call in the early evening would be beneficial to assist with preparing a hot meal and to help with personal care for bed time.

50. The occupational therapist recorded Mr L told her the Trust had explained his mother would have care in place from that day of discharge. The occupational therapist explained the discharge to assess full process and recorded they advised they could not guarantee care would start straight away. The family then contacted the agency that had been previously providing care to discuss reinstating the package.

51. On 12 May two occupational therapy assistants visited Mrs L at home to deliver and fit a swivel bather, wheeled commode, the bath step and bed lever.

52. From the nursing clinical advice, we understand the Trust should not have arranged a care package for Mrs L prior to her discharge, as it was the Trust’s intention for local services assess her at home and understand how much, if any, extra support she required. This is in line with pathway one of the discharge to assess model, which recognised that although Mrs L had new health/social care needs, as her family felt they needed an increase in her care package, this could be safely assessed at home.

53. When the occupational therapist assessed Mrs L at home on 11 May, the records do not indicate the therapist requested the Trust put in place a care package for Mrs L. The records show the therapist was aware the care agency agreed to a second visit for Mrs L but did not have a confirmed start date. As this assessment was conducted by a separate organisation which Mr L has not complained to us about, we have not looked at this other organisation’s actions.

54. Based on the records available to us, we cannot see the Trust informed Mr L it would arrange a care package following Mrs L’s discharge on 11 May. We can see the Trust discussed Mrs L’s discharge with Mr L and her daughter in law on 10 May and they all agreed for the Trust to discharge Mrs L home with a discharge to assess in place on 11 May. This is in line with the discharge to assess model.

55. As the therapist’s assessment of Mrs L on 11 May did not identify the need for the Trust to put in place a care package, there is no indication the Trust should have arranged a care package for Mrs L for these four days. As such, we do not consider anything went seriously wrong here and so we will not consider it further.

Catheter care

56. We then looked at Mr L’s complaint the Trust discharged Mrs L on 11 May without catheter care or support in the home.

57. The Trust apologised it sent Mrs L home with no arrangements or support in relation to her catheter. It said it expects staff to refer patients with a catheter to the district nurse with a supply of catheter bags and a catheter passport which contains information on how to care for a catheter at home. It explained the district nurse would then usually supply support and any further education. It said it asked the discharge and patient flow matron and the lead nurse for the ward to feedback an anonymised version of Mr L’s complaint to the nursing teams so they can reflect on their working practices and improve care for future patients.

58. There is therefore an indicated failing here, as the Trust has acknowledged.

59. Mr L said as a result of the Trust not arranging catheter care, his sister had to visit Mrs L each of the four evenings to change it. He said this caused his sister stress and inconvenience, due to the additional cost and time involved.

60. Mr L explained the effects on his sister were more about the stress and time commitment required and the impact on her daily life rather than the financial impact. He said the stress was more about having to be there at a set time each day to deal with the catheter and fitting the night bag immediately before Mrs L’s bedtime, so each visit was a couple of hours minimum. He said carers attended in the early evening and were able to fit the night bag, but this was a falls risk when Mrs L chose to move around the home and she sometimes tried to remove the bag. He also mentioned his father (Mrs L’s husband) could not change the catheter alone. In terms of the financial impact to his sister, Mr L said the visits were a four mile car journey in each direction plus the length of time she remained at Mrs L’s house.

61. This email from Mr L seems to suggest carers were able to visit in the evening after all, however, through the lifetime of the case Mr L has said the private carers were unable to visit for four days following Mrs L’s discharge on 11 May and so family had to visit these evenings to help with the catheter.

62. Our Principles for Remedy say that to put things right organisations should provide 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.

63. In this case, we can see the Trust explained what should have happened for Mrs L’s catheter care following her discharge on 11 May and apologised that this did not happen. It also explained the lead nurses would feedback Mr L’s concerns to the nursing teams involved to reflect on and improve their future practice for patients. We are satisfied this is in line with our Principles for Remedy. We also note these service improvements are one of the outcomes Mr L is hoping to achieve through making the complaint.

64. We would not be able to link Mr L’s sister’s financial costs as a direct impact of the lack of catheter care or support, as we cannot definitively say Mr L’s sister would not have visited Mrs L at home if the Trust had put catheter support in place.

65. We recognise Mr L has also included concerns about his sister having to visit every evening to change Mrs L’s catheter immediately before bed, even after the private carer’s evening visits, as the private carers would change the catheter ready for the night but this caused a falls risk for Mrs L if she wanted to move around the home before going to bed. This appears to involve concerns around the timing of Mrs L’s private carer visit in the evening, rather than the Trust’s actions and the impact this had.

66. Additionally, based on the information available, we cannot see Mrs L’s family made the Trust aware of the lack of catheter support and so we consider the Trust did not have an opportunity to resolve this at the time.

67. Based on the information above, there is an indicated failing in the Trust not arranging catheter care support following Mrs L’s discharge on 11 May 2023. We understand Mrs L’s family had to visit her in the evening to change the catheter for four days, until private carers could attend to help, as Mrs L’s husband was unable to change it. We recognise this caused Mrs L’s family stress and inconvenience for these four days. We therefore consider it was appropriate for the Trust to apologise and to demonstrate how it has learnt from Mr L’s complaint, in line with our Principles for Remedy.

68. We hope Mr L finds some reassurance that the Trust has taken learning and made improvements as a result of his concerns.

69. We understand Mrs L’s experience has caused the family great distress. We appreciate the time he has taken to explain he details of his complaint, and we thank Mr L for bringing these to our attention. We hope we have explained our decision clearly.

1. We have carefully considered Mr L’s complaint about Barnsley Hospital NHS Foundation Trust (the Trust). We were sorry to hear of the concerns Mr L bought to us and the distress he, his mother, and his family experienced. We do not wish to underestimate how difficult this has been for Mr L and his family.

2. We have seen no indication anything went seriously wrong in the Trust’s decision Mrs L was medically fit for discharge (MFFD) on 20 April and it discharging her on 11 May without a care package in place.

3. We have decided the Trust has already done enough to put right the impact caused as a result of the lack of catheter care support for Mrs L following her discharge on 11 May. Therefore, we have decided to take no further action.