A practice in the Bristol area

The Trust 3. Mr G complains about the Trust’s decision to discharge his wife in August 2022 and its lack of communication around aftercare.

4. He says his wife’s leg ulcer burst on 12 August and the lack of arrangements for home treatment caused further stress. His wife felt like a burden and he had to arrange for her to attend her GP Practice. This involved climbing 36 steps to and from their top floor flat three times a week for 10 weeks.

5. Mr G would like the Trust to explain why his wife was deemed not housebound and why it assumed her leg would heal.

The Practice 6. Mr G complains the Practice did not provide the aftercare it should have provided. He says his wife had COPD, oedema and an ulcerated leg.

7. He says his wife’s leg ulcer burst on 12 August and the lack of arrangements for home treatment caused further stress. His wife felt like a burden and he had to arrange for her to attend her GP Practice. This involved climbing 36 steps to and from their top floor flat three times a week for 10 weeks.

8. Mr G would like the Practice to explain why it did not provide aftercare to his wife.

9. Mr G and his wife lived in a flat on the top floor of a building where there was no lift. Following Mrs G’s admission to the Trust, it discharged her home on 5 August 2022.

10. The ‘discharge to assess’ model for managing transfers of care is also known as ‘home first’ or ‘step down’. This is about ensuring that patients are given the chance to continue their lives at home.

11. The Trust made a referral to the local community team, the Practice, before it discharged Mrs G. The referral was for wound care as Mrs G had a pressure sore and a wound on her hand. At the time of her discharge, Mrs G also had a haematoma on her leg (a collection of blood outside the blood vessels, often caused by trauma or injury).

12. The Practice made contact with Mr and Mrs G to assess the support they needed.

13. Mr G contacted his GP as he was concerned Mrs G leg needed to have a dressing on it. This resulted in Mrs G attending the GP Practice to have her dressings changed. She did so until she sadly died in October 2022.

17. 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.

The Trust

18. Mr G complains about the Trust’s decision to discharge his wife. We considered if the Trust acted in line with Annex D of the DHSC discharge guidance, which sets out the ‘criteria to reside’.

19. This guidance reflected that when any person is reviewed on a ward round, doctors should actively consider discharging them to a less acute setting. This should happen unless there is a clinical need or exception.

20. The ward round from 5 August shows Mrs G’s NEWS score (a tool to assess the degree of illness of a patient) was 0, her bloods were reviewed and were all fine, and she was ‘feeling much better’. The Trust had considered whether Mrs G needed a level of care that she would need to be in hospital to receive.

21. Our physician adviser explained there were no medical reasons for Mrs G to stay in hospital based on the criteria. The decision to discharge Mrs G was in line with the guidance.

22. We also considered if the Trust assessed Mrs G’s needs in the way it should have before discharging her, and if it made any necessary arrangements based on this.

23. Our nursing adviser referred to quality statement 3 of NICE QS136. This explains how discharge planning can help to make the transition home smoother.

24. The Trust assessed Mrs G and found there was no functional change while she was in hospital. She needed assistance with her hygiene needs which Mr G was happy to provide.

25. The medical team reviewed her and found she was medically fit for discharge. The orthopaedic team reviewed her and determined that no intervention was needed. The team expected Mrs G’s haematoma to disperse, as is often the case. The plan was for her GP to follow her up and repeat a blood test and chest X-ray.

26. An occupational therapy review took place when Mr G was present on 4 August. Mrs G was seen by the physiotherapist the same day who agreed the community therapy referral.

27. Mrs G was able to mobilise with a stick, her oxygen levels decreased when she did so but she recovered well indicating she was able to manage. The Trust was aware she lived in a top floor flat and the plan was for discharge to assess input simply for her mobility.

28. Annex C of the DHSC discharge guidance sets out pathways for the discharge to assess model. Patients and their families should be enabled to make informed choices about the discharge pathway that best meets the person’s needs.

29. The records reflect Mrs G was keen to go home and Mr G was happy to assist her with her hygiene needs. Mrs G was discharged on Pathway 0, a simple discharge home where no new or additional support is required to get the person home.

30. Mr G has told us how he felt compelled to seek assistance and about the physical toll on Mrs G from travelling to have her dressings changed. Our nursing adviser explained Mrs G had been deemed mobile and it is normal to attend clinics for dressings, unless the patient is bedbound. Mrs G was not bedbound, even after the haematoma burst.

31. Based on the advice we received, the Trust did everything it needed to, in line with the guidance. This is why we have decided not to investigate the complaint about the Trust further. We appreciate this does not change Mr G feels about his wife’s experience.

The Practice

32. We considered whether the Practice took appropriate action based on the referral it received from the Trust. The NMC Code says nurses must ensure patients’ needs are recognised, assessed and responded to.

33. The Trust referred Mrs G to the community team (the Practice) who rang and discussed this with her on 7 August. Even though there was no reference to any nursing needs in the referral, a nurse from the Practice checked this with Mr and Mrs G. They did not mention any nursing needs so Mrs G was discharged from the district nursing.

34. A discharge to assess therapist visited Mrs G on 8 August and noted her wound but there were no issues raised about her care. There were no concerns that indicated Mrs G needed district nursing input.

35. Our nursing adviser said the Practice’s actions were in line with, and above, what would have been expected. This is why we are not investigating the complaint about the Practice further.

36. We want to thank Mr G for the time he has taken to bring his complaint to us. Our decision is not intended to diminish his distress and upset. We hope it is clear why we will not be taking his complaint further.

1. We have carefully considered Mr G’s complaint about the Trust and the Practice. We recognise how strongly he feels about the care his wife received before she sadly passed away. We were sorry to hear of his loss and the lasting impact it has had.

2. We have seen that both organisations acted in line with the relevant guidance. We understand Mr G may continue to feel differently. We hope the explanations in this statement show him why we have seen no indication anything went seriously wrong with Mrs G’s care.