Move to orthopaedic ward on 27 October
20. Dr M is concerned staff moved Mr M from the respiratory ward to an orthopaedic ward on 27 October when he was recovering from COVID-19. Dr M says this ward was not able to meet Mr M’s needs and there were patients infected with COVID-19 on the ward, putting her husband at risk of reinfection. We understand why Dr M is so concerned about this move.
21. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we have not found any indication this ward move had a negative impact on Mr M or resulted in him becoming reinfected with COVID-19.
22. Our adviser said Mr M’s physiological observation charts from 27 October show he was clinically stable for transfer. He also explained that at this time, Mr M was only on one litre of oxygen and met the rest of the NHS hospital discharge service policy criteria for discharge.
23. The Biobank study found that 99 percent of people who tested positive for COVID-19 retained antibodies for up to three months after being infected. This means that at the time of the transfer, Mr M would still have had very high levels of protective COVID-19 antibodies and was not at risk of re-infection on the orthopaedic ward.
24. Our adviser said that, from review of the medical records from the second hospital admission, there was no evidence Mr M became reinfected with COVID-19. We also note that Mr M tested negative for COVID-19 on three occasions following readmission.
25. Having taken account of all the evidence, we can see no indications this ward move affected Mr M’s health. This is because the evidence we have seen suggests Mr M was stable enough for transfer and the ward move is unlikely to have resulted in him being reinfected with COVID-19. We hope this provides some reassurance to Dr M about this concern.
Steroid dose
26. Dr M complains staff did not prescribe her husband a high enough dose of steroids for his COVID-19 infection during his first admission. She says Mr M only received these steroids during his second admission to hospital.
27. The COVID-19 rapid guideline advises to offer 6mg dexamethasone (a type of steroid) for up to ten days to people with COVID-19 who need supplemental oxygen. It says to continue corticosteroids for up to ten days unless there is a clear indication to stop early, including discharge from hospital.
28. Mr M was receiving supplemental oxygen during his stay in hospital and so doctors prescribed him 6mg of dexamethasone in line with the NICE guidance. We can see Mr M had this medication at this dosage for nine days.
29. On 25 October, a doctor left a note to say to decrease the dosage to 4mg to wean Mr M off steroids. The treating team gave Mr M 4mg daily up to his discharge and continued this following discharge.
30. There is no note in the records as to why the doctor decided to reduce the steroids on day nine. However, our adviser said the small reduction from 6mg to 4mg for one day would not have made any difference.
31. This is because the average duration of dexamethasone treatment for patients successfully treated in the RECOVERY trial was seven days. Mr M received this treatment for longer than this.
32. In summary, there is a small discrepancy between the NICE guidance and what the Trust prescribed Mr M. We can see no indication this had a negative impact on Mr M.
Decision to discharge from hospital 28 October
33. Dr M questions if her husband was suitable for discharge on 28 October and if he should have had different tests prior to discharge to establish the state of his lungs. She says her husband deteriorated at home and was readmitted to hospital a week later. We appreciate why this readmission has caused Dr M to question Mr M’s suitability for discharge.
34. 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 in the decision to discharge Mr M.
35. The NHS hospital discharge service policy outlines the criteria for a patient to remain in hospital. The criteria includes if a patient requires ITU or HDU care, oxygen therapy or non-invasive ventilation, or IV fluids or medication.
36. It also includes if they have a NEWS score (a tool to detect clinical deterioration in patients) of more than 3, a diminished level of consciousness, acute functional impairment or if they are in their last hours of life. If the patient does not meet any of the criteria, then the guidance advises to consider discharging the patient.
37. Our adviser reviewed Mr M’s medical record and said Mr M did not meet any of the criteria to reside in hospital. The only criteria our adviser was initially unsure of was whether Mr M required oxygen at the time of discharge. However, we sought more records from the Trust which showed Mr M was not requiring oxygen at all on the day of discharge.
38. Taking this advice into account, we have seen no indications of failings in the decision to discharge Mr M as he did not meet any of the NHS criteria to reside in hospital.
39. Regarding Dr M’s complaint that Mr M needed further tests or treatment prior to discharge, the GMC guidance says doctors should:
• adequately assess the patient’s conditions, taking account of their history, their views, and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations, or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.
40. Our adviser was not concerned the Trust should have carried out further tests prior to discharging Mr M. We can see the Trust made a plan at discharge for Mr M to have a follow up in the chest clinic for a chest X-ray in 12 weeks. He said the plan at discharge was in line with the GMC guidance.
41. Taking this advice into account, we have seen no indications of failings in the decision to discharge Mr M. This is because there is no indication Mr M needed further tests of treatment and the plan to discharge him was in line with GMC guidance.
Discharge process
Oxygen and follow up care
42. Dr M complains the Trust’s discharge process was poor. She complains the Trust did not give her husband any oxygen on discharge which she feels it should have done. Dr M is also concerned the Trust did not arrange any aftercare of follow up appointments for Dr M. We were very sorry to hear of how difficult Dr M found the discharge process.
43. The GMC guidance says to ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’.
44. We can see that on the day the Trust discharged Mr M, he was not receiving oxygen. His oxygen saturations were 88 percent after exertion which our adviser said was a safe range.
45. Our adviser said that if Mr M had still been requiring oxygen on the day of discharge, he would have expected the Trust to organise home oxygen for him or keep him in hospital until it had weaned him off this. This would have been in line with GMC guidance to arrange appropriate treatment.
46. As Mr M was not requiring oxygen at all on the day of discharge, we would not have expected the Trust to arrange home oxygen for him.
47. We can also see the plan on discharge was for the chest clinic to see Mr M for a chest X-ray in 12 weeks’ time with a recommendation for follow up from community respiratory nurses. Our adviser said this was in line with the GMC guidance for arranging appropriate care and treatment.
48. Taking into account this advice, we have seen no indications of failings in either the decision not to provide oxygen at discharge or in the Trust’s aftercare plan.
Ambulance
49. Dr M complains the Trust did not discharge Mr M home in an ambulance. On discharge, Dr M says she drove Mr M home in her car which was stressful.
50. The NHS hospital discharge service policy says hospitals should confirm arrangements to transport people home from hospital prior to discharge. It says this should be via family or carers, voluntary sector, or taxi. It says hospitals should use non-emergency patient transport (an ambulance) as a last resort.
51. We cannot see any mention of Mr M requiring an ambulance at discharge in his medical records. Our adviser said patients usually only require an ambulance if their mobility is too poor to go in a car. He explained this did not apply to Mr M as there are various notes in his medical records which say that he was mobilising well prior to discharge.
52. Taking this advice and guidance into account, we do not feel there are indications of failings in the Trust not arranging an ambulance for Mr M. This is because Mr M was mobilising well and did not require an ambulance in line with the NHS hospital discharge service policy. We are in no way disputing how stressful Dr M found this journey though.
Discharge paperwork
53. Dr M says the Trust did not provide her or Mr M’s GP with her husband’s discharge paperwork until over a week following discharge causing confusion. She also says there is a discrepancy between the discharge note provided to her and the one provided to the GP. We appreciate the frustration these issues caused Dr M.
54. We are an ombudsman provided for, and funded by, the public. We therefore need to ensure we maintain a balance in our work between supporting those who complain to us to get a remedy for the injustice they have experienced and ensuring we use our resources to focus on those where we can achieve the most impact.
55. This means that in some circumstances we will decide not to consider a case where someone tells us the injustice they experienced has not had a significant or lasting impact.
56. We have considered the impact Dr M told us the issues with the discharge paperwork had. She told us the Trust not providing the discharge letter and the discrepancies caused distress and confusion at the time.
57. We agree that these issues would have caused Dr M confusion and distress at the time which would have lasted for a short duration. As such, we have decided not to take these issues forward to a detailed investigation. We appreciate this may be a disappointing decision for Dr M.
Poor communication
Orthopaedic ward
58. Dr M complains that when her the Trust transferred Mr M to the orthopaedic ward, the staff did not provide her with any updates.
59. Regarding communication, the GMC guidance says doctors must:
• give patients the information they want or need to know in a way they can understand • be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
60. Our adviser said that given Mr M was only on the orthopaedic ward for 24 hours and was clinically stable, there was no indication for the doctors to contact his family with an update. It appears the Trust communicated with Mr M on the 28 October and could reasonably have expected he would update his family about the fact the Trust was planning to discharge him.
61. Taking this advice into account, we can see no indications of failings here as it appears the doctors updated Mr M directly who would have been able to update his family himself. Given the short length of stay on the ward we do not feel we can be critical of the Trust for not proactively providing an update during this time.
Second admission
62. Dr M complains about poor communication during Mr M’s second hospital admission regarding his decline. Dr M says there was no recognition that her husband was at the end of his life and doctors kept informing her that he was not at this stage yet, even on the day he died. She says they did not make her aware he had declined until she attended the hospital for the third time on the day of his death.
63. The NICE guidance for the care of dying says doctors should discuss the dying person's prognosis with them (unless they do not wish to be informed) as soon as it is recognised that they may be entering the last days of life and include those important to them in the discussion if the dying person wishes.
64. We have carefully considered Mr M’s medical records and can see there are indications the Trust could have communicated that Mr M was dying sooner. We can see that Mr M began to deteriorate around 11:50am on the day he died. However, there is no documented evidence the Trust communicated that he was dying to Dr M until around 7:45pm.
65. Dr M is understandably very distressed by this and feels she was unable to say a proper goodbye. We can only imagine how devastating this was for her at an already difficult time.
66. We have spoken to the Trust, and it has agreed to take further action to try and address this part of Dr M’s complaint. As an outcome to her complaint, Dr M told us she would like the Trust to acknowledge its failings and put service improvements in place to make sure similar mistakes do not happen again. The Trust has agreed to carry out these actions.