12. 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 found any indications that something has gone wrong.
Discharge 13. Mrs G feels the Trust should have discharged her mother much sooner than it did. Our adviser explained Mrs R was admitted for investigations into her swollen knee and the possibility of a serious joint infection, septic arthritis (this is different to sepsis).
14. There is no evidence Mrs R’s discharge was delayed or that she was kept in hospital unnecessarily. For the first few days, she was on intravenous (IV) antibiotics and undergoing investigations. This would only have been possible in hospital and in line with the national guidance on hospital discharge, justified her being in hospital.
15. Mrs R being ‘medically suitable for discharge’ was first mentioned on 1 October. The Trust acted in line with the national guidance on hospital discharge as this was the date when the Trust stopped her IV fluids.
16. The Trust wanted a palliative care nurse to see Mrs R before it discharged her and Mrs R deteriorated quite dramatically on 2 October. Our adviser said this means there was only a very small window in which the Trust could have looked at sending her home sooner. This is why we have not identified any indication of a failing.
Nutrition and hydration 17. Section 1.2 of NICE CG32 covers screening for malnutrition and the risk of malnutrition. It refers to using a screening tool such as the Malnutrition Universal Screening Tool (MUST). The Trust acted in line with this.
18. Patients at low risk of malnutrition are indicated by a MUST score of 0. Mrs R’s MUST score was 0 so there were no nutrition concerns at the outset and when it was repeated.
19. There are references to Mrs R eating and drinking a normal diet at the start of her admission. There is an entry on 30 September noting Mrs G had called concerned her mother had not eaten since lunchtime the day before.
20. Mrs R’s oral intake is noted as ‘moderate’ during a ward round on 30 September. The Trust made a referral to the palliative care team the same day. There are further references to Mrs R eating and drinking a normal diet, or eating, from 2 to 6 October.
21. Our adviser said there is no evidence of an issue with Mrs R’s nutrition or hydration. The nursing notes say fairly consistently that she was eating well until she started to become unwell around 2 October. The food charts indicate she was being monitored and there was no concern about her intake. We have therefore seen no indication of a failing in relation to this.
Visiting 22. NHS England shared guidance on visiting hospitals in 2021. This said healthcare organisations should facilitate visiting as far as possible, limiting this to one close family contact at the bedside. For patients ill enough that they could die within the next few days, organisations should take a risk-based approach to decide if the arrangements can be relaxed.
23. The Trust’s complaint response said due to the pandemic, visiting was restricted to certain circumstances. ‘The most common reasons are if a patient is in the last two weeks of their life or they have dementia and the absence of the visitor causes distress to the patient. [...] at the time, it was not felt that your mother fitted into either category. Therefore, visiting was not permitted whilst she was an inpatient on [the COVID-19 ward].’
24. There is reference to Mrs R having one visitor in the records, and references to family members being present. The Trust also appears to have asked them to come in at times. It appears a son of Mrs R asked if other family members could visit on 10 October and was told they could, but not in groups.
25. Given the risks associated with visiting, the Trust’s actions appear to be in line with the guidance. This is why we have not identified any indication of a failing here.
Communication 26. Point 33 of GMC ‘Good medical practice’ said doctors ‘must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.
27. Our adviser noted in Mrs R’s records, there is quite a lot of detailed information on communication about being unwell and her prognosis being poor. It seems there were multiple detailed discussions with family members, including that she had deteriorated and was dying.
28. This is reflected in the Trust’s complaint response which said ‘on 11 October 2021, the day [Mrs R] was discharged, her observations had led to concerns that her condition was deteriorating and her prognosis was poor. Her family members were advised of that and in accordance with the family’s and [Mrs R]’s wishes, she was to be discharged for palliative care at home. [Mrs R] was sent home with oxygen and a syringe driver to administer comfort medications and was expected to pass away within days.’
29. While this is clear in the records, the family may not have taken on board the information at the time. Based on what we have seen, the Trust appears to have acted in line with the GMC guidance. We recognise Mrs G considers her mother death and deterioration unexpected, and we hope our investigation will reassure her about the Trust’s actions.
Cancer 30. We appreciate Mrs G’s perspective that the mention of cancer on her mother’s discharge paperwork was ‘erroneous’.
31. Point 44 of ‘Good medical practice’ says doctors ‘must contribute to the safe transfer of patients between healthcare providers and between health and social care providers. It says this means they must share all relevant information with colleagues involved in their patients’ care within and outside the team.
32. We note Mrs R had been undergoing investigations before her admission. During it, there is an entry on 29 September suggesting the Trust spoke to Mrs R about whether she wanted to have further investigations into the suspected gastric malignancy. There is an entry regarding a discussion with Mrs G too, where it seems further investigations were declined.
33. Our adviser said it appears highly likely Mrs R had gastric cancer, as her presentation was in keeping with that. She was receiving treatment for infection for more than a week but the Trust did not identify where the infection was. Our adviser said cancer can sometimes imitate an infection, so with the benefit of looking at this retrospectively, it may be that this was the cause of her abnormal bloods.
34. Our adviser also explained occasionally a scan will be misinterpreted so best practice is to get a biopsy sample to confirm the diagnosis. Commonly, someone may be too frail to get this type of sample, so the situation may be monitored. This was the case for Mrs R.
35. Our adviser said it was right for the Trust to share with the community team that one of her underlying conditions was cancer. This was in line point 44 of GMC ‘Good medical practice’ which covers continuity and coordination of care.
36. There was a strong suspicion of cancer based on the CT scan and profound anaemia, which was otherwise unexplained. The discharge summary accurately reflects this.
37. Overall, based on the available information and the advice we received, there is no indication of a failing in relation to issues Mrs G raised with us.
38. It is clear Mrs G has been deeply affected by her bereavement. We would like to offer our condolences for her loss. We hope our investigation reassures her about the care her mother received and it is clear why we have decided not to consider the complaint further.