Discharge on 23 March 2023
13. Mr G told us that when his father was discharged on 23 March he was bed-bound, completely immobile and not fit to leave the hospital. We understand how stressful it was for Mr G and the family who looked after Mr M when he got home.
14. The medical records show the medics considered Mr M to be fit for discharge from a medical perspective, and he was waiting for equipment and a package of care to be put in place before he was discharged. The records further document that Mr M was not willing to give his apartment key to anybody to allow this to happen, and that he was insisting on discharging himself.
15. Our adviser said the doctor and the deputy director of nursing explained all the risks to Mr M. They acted in line with the discharge guidance which says ‘where a person has mental capacity to make a decision about their care and support at the point of discharge, health and social care professionals should support them to manage their own risk’.
16. The records show the staff explained the risks, including falling, injuring himself and having to come back to hospital, and that in the worst case scenario he could risk his life. The Trust offered Mr M the alternative of going to the reablement facility. The staff explained self discharge was an unwise decision and documented that he ‘clearly has capacity to make this decision’.
17. Our adviser said the actions of the Trust in relation to the discharge were in line with the guidance, and went beyond what was expected. The Trust offered to have the equipment delivered to the ward instead of his home, and for Mr M to stay in hospital and take receipt of the equipment on the ward. Mr M refused and signed self-discharge paperwork so the Trust provided discharge medications and a discharge letter.
18. For these reasons we did not find any failings in relation to Mr M’s discharge on 23 March.
Rehabilitation at the reablement facility
19. Mr G says the family were told Mr M would receive extensive physiotherapy at the reablement facility as part of his rehabilitation and recovery, to regain some level of independence. He said the reablement facility discharged him less than a week after admission, as he was deemed medically fit and ready for discharge.
20. The records show at the point Mr M was admitted to the reablement facility he was medically fit and had no acute medical issues that required him to be in hospital. He had been brought back to hospital because his apartment was mouldy and lacked heating.
21. Our adviser explained when a patient is in hospital it is usual for the hospital to undertake an assessment of their mobility and a physiotherapist is involved as needed. This is outlined in the discharge guidance ‘Where patients need short-term therapy-led rehabilitation […] these needs should be identified as soon as possible in hospital’. We can see this happened and a physiotherapist assessed Mr M.
22. The physiotherapy records show Mr M was struggling with his movements from sitting to standing and he was ‘not at baseline’ (worse than usual for him). The stay in the reablement facility was for physiotherapy to try and improve his mobility back to his baseline so he could safely transfer himself around to reduce the risk of falls. The use of a reablement facility in this way is in line with the discharge guidance.
23. The records show from 17 April Mr M was able to transfer and move with a rollator frame and the assistance of one person. He was discharged with a package of care and community therapy, which is in line with the discharge guidelines ‘Discharge home (to usual place of residence or temporary accommodation) with health and/or social care and support’.
24. We recognise the physiotherapy input did not meet Mr G’s expectations and we are sorry for the concern this caused. We have found it was in line with Mr M’s assessed needs and so we have not found any failings.
Discharge on 18 April
25. Mr G told us the Trust discharged his father on 18 April when he was not fit for discharge. He said his father was unable to walk or lift himself up.
26. As we outlined in paragraph 23, Mr M was able to mobilise on 17 April. Our adviser said there are no specific guidelines about when a patient may be medically fit or unfit for discharge. He explained this judgement is a core part of overall clinical practice.
27. The records show Mr M’s clinical observations prior to discharge were within acceptable limits and his blood pressure was reasonable. On 18 April the Trust carried out a bladder scan which showed Mr M was not retaining a significant amount of urine after the removal of his catheter. The day before discharge the records show Mr M was eating and drinking well, in a sociable mood and his observations were stable. Our adviser said there was no information in the notes to suggest Mr M was not medically safe for discharge.
28. For these reasons we did not find any failings in the decision to discharge Mr M on 18 April.
Urinary Tract Infection
29. Mr G said the Trust did not detect or treat his father’s UTI during this second admission, prior to discharge on 18 April. We understand why he has these concerns as his father sadly died shortly after his readmission on 20 April.
30. Mr M had retention of urine (not emptying his bladder properly) when he was readmitted on 5 April and required a catheter. The Trust acted in line with the NICE guidance CG97, which says ‘Immediately catheterise men with acute retention'.
31. On 5 April the Trust carried out a urine dipstick analysis which did not show any abnormality to suggest Mr M had an infection.
32. The Trust removed Mr M’s catheter on 17 April. As outlined in paragraph 27, the Trust carried out a bladder scan after removal, which confirmed he was emptying his bladder properly and not retaining an excessive amount of urine.
33. Our adviser explained that a doctor would only give antibiotic treatment if there are symptoms of a urinary tract infection (such as lower abdominal pain, fever, pain around the genitals, and if no catheter is present then increased frequency of urination or painful urination).
34. Antibiotic treatment is not recommended unless there are signs of infection as it is both ineffective at removing bacteria from the catheter, and puts the patient at risk from side effects of the antibiotics (including developing resistance to antibiotic treatment for when antibiotics are required).
35. This is the approach that is recommended in NICE guidance NG113, which says ‘catheter-associated urinary tract infection (UTI) is a symptomatic infection of the bladder or kidneys in a person with a urinary catheter. The longer a catheter is in place, the more likely bacteria will be found in the urine [bacteriuria]; after 1 month nearly all people have bacteriuria. Antibiotic treatment is not routinely needed for asymptomatic bacteriuria in people with a catheter’.
36. Our adviser said that prior to discharge, Mr M’s physical observations were within acceptable parameters, with no fever. There is no evidence he was, or should have been suspected to be, suffering from a urinary tract infection immediately prior to discharge.
37. For this reason we think the Trust’s approach was in line with both sets of guidance and we have not seen any failings.
Conclusion
38. We have not identified any failings in the care and treatment the Trust gave Mr M as the actions of the Trust were in line with the relevant guidance. We thank Mr G for sharing his concerns with us. We hope this report fully explains the reasons for our decision and provides the family with reassurance about the care and treatment the Trust gave Mr M.