11. Before we decide if we should conduct a detailed investigation of a complaint, we look at if there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We must also consider if there are signs the events complained about had a negative effect which the organisation has not put right.
Carers Charter
12. Mr Y complains he should have had special visiting arrangements to see his mum, but hospital staff refused this arrangement. He says this was not in line with the Trust’s Carers Charter.
13. The Carers Charter sets out carers will have open visiting, especially during protected mealtimes. Nurses will also offer carers identification on the ward so staff can identify them easier, thereby encouraging more open communication.
14. The Trust’s website at the time explained, ‘Where there are visiting restrictions in any of our ward areas, the ward team will let you know on admission.’ Its website did not mention the Carers Charter or if the Trust had suspended it at the time.
15. The Trust’s complaint response explained its Carers Charter was not in place during Ms A’s hospital admission. The Trust said it had paused this due to concerns about the spread of COVID-19.
16. ONS statistics show there was an increased percentage of people testing positive for COVID19 at the time. Staff had to mitigate the spread and risk of infection against allowing visitation to patients.
17. The Trust updated its website in December 2022 to include information for carers and how the special arrangement for them was in place.
18. We recognise how stressful this was for Mr Y at the time and understand he felt disrespected by staff not allowing him special visiting arrangements.
19. Given the information the Trust shared online, as well as its explanation in the complaint response, we consider staff were following the relevant guidelines when they advised Mr Y he would have to follow the standard visiting guidelines.
20. We understand the frustration Mr Y experienced when nurses did not allow him to care for his mum in the way he wanted.
21. We can see the Trust shared Mr Y’s concern at the ward’s safety meeting. Further, it reinstated the Carers Charter and resumed actively promoting it. Although we consider nothing went wrong we are satisfied it has acted on his concerns.
Pneumonia
22. Mr Y says doctors diagnosed his mum with a chest infection when she attended hospital on 6 October. He says doctors spoke about treating this throughout her period of care in hospital. He says her death certificate from 4 December recorded pneumonia as cause of death, but doctors barely mentioned it whilst caring for her.
23. Mr Y is concerned doctors missed her pneumonia when she first attended hospital on 6 October.
24. Pneumonia is an infection of someone’s lungs. It is also known as a chest infection or lower respiratory tract infection. It can also be referred to as CAP, which stands for community acquired pneumonia. For clarity, we have referred to it as pneumonia throughout this statement.
25. NICE guideline Pneumonia in adults: diagnosis and management explains a diagnosis is made based on the patient’s symptoms. A cough is usually the main symptom, and can be accompanied by either a high temperature, mucus in someone’s airways, breathlessness, wheeze, or chest pain.
26. If a doctor suspects pneumonia they can confirm it with a chest X-ray. Pneumonia would show up as a shadow on the X-ray not due to any other cause. If doctors diagnose pneumonia they should assess the risk it poses to the patient using the CRB65 score. We have explained this score below.
27. NICE instructs doctors to start antibiotics as soon as possible after diagnosing pneumonia. If the patient is at increased risk then doctors should consider admitting them to hospital for monitoring.
28. Our adviser explained doctors assessed Ms A when she arrived at hospital on 6 October 2022. They found her legs gave way whilst walking which caused her a fall at home. She also had a cough, a fast heart rate and reduced oxygen levels.
29. A blood test also showed Ms A had a raised white blood cell count of 12.9 and raised Creactive protein level of 143. These readings in a blood test indicate someone has an infection. They therefore diagnosed Ms A with pneumonia.
30. Doctors assessed the risk this pneumonia posed to Ms A by working out her CRB65 score. They calculated this score by awarding one point for each of the following features Ms A had: • Confusion – recent • Respiratory rate 30 breaths/min or greater • Blood pressure - systolic of 90 mmHg or less, or a diastolic of 60 mmHg or less • 65 years of age or older 31. A CRB65 score of two identifies the patient is at increased risk of death. In these instances, care in a hospital should be considered. Ms A scored two on this scale.
32. Following this assessment doctors started Ms A on antibiotics to fight the pneumonia infection. They also admitted her to hospital to manage her ongoing symptoms. They followed this up with a chest X-ray on 10 October to confirm the diagnosis. Therefore, doctors identified Ms A’s pneumonia and managed it in line with relevant guidelines.
33. We understand the concern Mr Y has experienced because of what happened. We hope our finding reassures him doctors identified his mum’s pneumonia promptly and treated it in line with guidance.
Discharge on 5 November
34. Hospital discharge is the final stage of an individual’s journey through hospital. It comes following the completion of their acute medical care.
35. Government guidance on hospital discharge sets out patients should return to a familiar setting whenever possible, as they often respond well to the comfort of their home environment. The home environment should be adapted to the individual with support in the community to help them recover in a safe, appropriate, and timely way.
36. This guidance and GMC Good Medical Practice say doctors should consider a patient’s current condition when discharging them. Doctors should be satisfied the patient does not need close monitoring or treatment. This includes things like intravenous medicines, an oxygen mask or frequent blood tests.
37. Furthermore, any discharge decision should involve cooperation between the multiple disciplines responsible for the patient. In this instance it was doctors, occupational therapists, and the physiotherapy team. These are specialists who help patients live comfortably in the community and restore movement to those affected by illness.
38. Our adviser explained Ms A had completed the immediate treatment needed for her pneumonia and her fall. Occupational therapists and physiotherapists had arranged an ongoing package for community carers to deliver at Ms A’s home four-times per day.
39. From the discharge summary we can see Ms A was stable and her condition was continuing to improve in response to the hospital treatment. Further, she no longer needed active management. This meant the specialisms involved in caring for Ms A agreed she was fit enough to be looked after at home with the package of care they had arranged.
40. Mr Y says his mum experienced an uncontrollable bowel movement accompanied by excruciating pain at home on the night she returned home. He says this caused him to call an ambulance for her and the paramedics took his mum straight back to hospital saying doctors had ‘misdischarged’ her. Mr Y believes this indicates she was not fit enough to go home.
41. We are sorry to hear Ms A’s condition that evening meant she had to return to the hospital. We acknowledge how distressing this must have been for her and her son.
42. In considering what happened we have focused on the information available to doctors when they sent Ms A home on 5 November. Having done so we can see they accounted for her condition at the time and how it had improved during her time in hospital. They had also planned how they would continue dealing with her ongoing problems in the community.
43. Therefore, Ms A’s discharge happened in line with the relevant guidelines.
Discharge communication
44. Mr Y says hospital staff were planning the discharge alongside adult social services since 1 November. He is unhappy he only found out about these plans in the discharge letter on the morning his mum returned home. He feels hospital staff should have had a sit-down meeting with him to discuss her discharge as he was unsure about the care plan in place.
45. Government guidance says healthcare staff should work together with individuals, their families and their unpaid carers when planning discharge. If care, treatment, or support is needed then the individual and those close to them should be fully involved in considering what form that might take and in weighing up the risks and benefits of the options available.
46. Our adviser explained the therapy teams recorded the conversations they had with Mr Y about plans to send his mum home.
47. On 19 October, the physiotherapy team spoke with him over the phone and he agreed to continue providing all the care he needed upon discharge. He was also attempting to put community therapy in place but hospital staff reassured him they would be able to do it for him.
48. Occupational therapy and physiotherapy staff called Mr Y again two days later. They shared his mum’s concerns that he would need extra support to look after her. Mr Y was surprised to hear this update so staff agreed to reassess his mum’s needs on 24 October and discuss the new plan with him then.
49. An occupational therapist met with Mr Y when he visited the ward on 24 October. Mr Y confirmed his mum’s wanted to return home instead of to a rehabilitation centre. He was also happy care staff would visit his mum four-times per day.
50. Mr Y added he would continue helping his mum with her meals and a hospital bed had been installed downstairs in their home ready for her discharge.
51. The discharge checklist from 5 November shows ward staff spoke to Mr Y on the morning of his mum’s discharge. They also sent Ms A home with the discharge letter summarising the care she received in hospital and the arrangement at home.
52. We appreciate Mr Y found it worrying to have his mum return home and be unsure about what care was in place for her. Having considered what happened we are satisfied hospital staff discussed discharge planning with him in line with the guidelines and shared the plan in the way we would expect.
COVID-19
53. Mr Y complains the Trust gave his mum COVID-19 whilst she was an inpatient.
54. The Trust’s COVID-19 policy from the time says it should test inpatients for the disease upon admission. In line with broader NHS guidance, it should also retest patients five to seven days afterwards. This broader guidance also explains it is probable a patient caught COVID-19 in a hospital setting if they test positive more than seven days after admission.
55. Ms A tested negative for COVID-19 when staff admitted her to hospital on 6 October. A followup test five days later returned positive.
56. We got clinical advice on what happened. Our adviser explained because Ms A tested positive for COVID-19 five-days after admission it is possible she caught it outside hospital. The disease’s incubation period could explain the delayed diagnosis. This is where someone has caught COVID-19 but does not have symptoms or test positive yet.
57. There is no way for us to determine if Ms A caught COVID-19 before or after her hospital admission. This means we cannot reliably say the Trust’s actions resulted in her getting COVID-19.
58. It has been devastating for Mr Y that his mum sadly caught COVID19, especially given his efforts to keep her safe during the pandemic. We recognise our decision does not give Mr Y the definitive answer he wants but hope we have clearly explained the reason we could not do so.