Northern Lincolnshire and Goole NHS Foundation Trust

3. Dr R complains in September 2023 the Trust incorrectly considered him fit for discharge.

4. Dr R claims because the Trust incorrectly discharged, the Trust left him in unnecessary pain and in urinary retention following damage to his disc. Dr R says he does not know the long-term effects of being discharged early as he is waiting for follow up investigations with a surgeon. He explains this causes him added worry, uncertainty, and distress.

5. Dr R would like an apology and service improvements.

6. Dr R has a history of disc disease in his lower back and is on a waiting list for surgery. On 8 September 2023, he further injured his back whilst sitting in a chair. The ambulance service transported Dr R to the emergency department (ED) on 10 September 2023.

7. A consultant assessed Dr R and they ordered a magnetic resonance imaging (MRI) scan. The scan showed Dr R had a disc bulge in his lower back (L5/S1) which was compressing his spinal nerve roots.

8. On 11 September 2023, the Trust contacted neurosurgeons in Hull. They agreed the neurosurgeons would discuss Dr R’s case at the multi-disciplinary team (MDT) meeting in the morning. The Trust decided to admit Dr r until after the MDT meeting.

9. At 2.28am, on 12 September 2023, a junior doctor discharged Dr R before the MDT meeting. The Trust accepts that this was an unsafe discharge and Dr R should have remained on the ward.

Unsafe discharge.

12. Dr R told us on 11 September, Trust staff had agreed to hold an MDT meeting to discuss his treatment. The plan was to explore if the Trust needed to transfer him to a neurosurgeon team for further investigations and care. Before the MDT meeting, he says a junior doctor incorrectly discharged him and sent him home. Dr R says this was unsafe due to the severity of his back injury and the potential of paralysis.

13. In its response of 17 October, the Trust fully accepts that Dr R’s discharge was unsafe. It has apologised for this error and confirmed the doctor should not have discharged him. The Trust explained it had a clear plan and advice from a neurosurgeon in place to say they needed to review his care at an MDT meeting. It accepted the doctor did not follow this advice correctly and this led to the Trust incorrectly discharging Dr R at 2:28am on 11 September.

14. Both parties are in full agreement the Trust discharge of Dr R was unsafe.

15. Our ‘NHS complaints standards’ (December 2022) say we expect organisations to ‘support and encourage staff to be open and honest when things have gone wrong.’ It is also important ‘staff recognise the need to be accountable for their actions.’ Finally, our standards say when an organisation investigates a complaint it should ‘explain why things went wrong and identify suitable ways to put things right for people. Staff should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.’

16. Dr R explained he wanted to bring this complaint to us, to make sure the Trust learnt from its mistakes. He was concerned ‘this error could happen again’ and he wanted reassurance the Trust had taken appropriate action to prevent this from happening. We can understand why Dr R feels strongly about his complaint. This must have been a very distressing experience for him, and we are sorry to hear of the pain and upset this caused.

17. In its response, the Trust and the junior doctor apologised for the mistake it made when it discharged Dr R. It confirmed the junior doctor had also done a personal learning exercise on the incident to prevent similar mistakes in the future. We consider these actions are in line with our NHS complaints standards. We can see the Trust correctly encouraged its staff to be ‘open and honest when things had gone wrong.’ We can also see the junior doctor was held accountable for the error which occurred and gave a ‘meaningful and sincere apology’.

18. On 1 August 2024, we contacted the Trust complaints team to ask them to review Dr R’s case for any additional learning. On 2 September 2024, the Trust provided an update on the new processes it has implemented since Dr R’s discharge. It says:

‘We would like to reassure Dr [R] since he raised his complaint, a new process has been introduced into the Emergency Department. This new process is the introduction of two hourly board rounds whereby clinical staff meet to discuss patients within the Emergency Department, providing an up-to-date handover of the patient’s suspected diagnosis and treatment plan.

Junior clinical staff are involved in these discussions and are challenged regarding their management of their patients and are supported if they require senior clinician input. This ensures information is shared regularly within the clinical team and junior clinicians receive adequate support which enhances reflection and learning whilst providing a good standard of patient care.

We would like to reiterate our sincere apologies to Mr [R] for his experience within the Emergency Department and for the distress this caused.’

19. We consider the Trust has acted in line with our NHS complaints standards. It has undertaken further work to ‘identify suitable ways to put things right’. It has made wider service improvements, to change its process and support its staff to minimise the risk of similar mistakes happening in the future.

20. We shared this information with Dr R. He confirmed he was also satisfied with the Trust’s response and was pleased to see it had implemented wider service improvements. As such, we are satisfied we do not need to take any further action regarding this complaint. We would like to thank both parties for their time and effort during this process.

1. We are sorry to hear the Northern Lincolnshire and Goole NHS Foundation Trust (the Trust) incorrectly discharged Dr R in September 2023. We appreciate when it discharged him was suffering from pain and urinary retention. This must have been an upsetting and distressing experience. We would like to thank him for bringing this matter to us and wish him well with his ongoing recovery.

2. In its response to this complaint, the Trust acknowledged it did not discharge Dr R safely and apologised for the error it made. As part of this process, it has agreed to reflect, learn, and put in place service improvements to prevent this from happening again. Dr R told us he is happy these steps are sufficient to put his complaint right. We are pleased to see the Trust has now resolved this complaint and we will not take any further action.