Care and treatment
15. Miss A believes doctors were wrong to discharge her father from the Hospital. She says he needed close monitoring that was not available for him at home. She says he needed dialysis. She also says it was wrong for doctors to discuss follow up arrangements with her father when he was confused. She questions whether the follow up arrangements were put in place. Miss A also believes clinicians should have prescribed oxygen for him to have at home.
16. Doctors should have followed Good Medical Practice which says they must provide a good standard of care. This includes carrying out adequate assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange timely treatment and appropriate investigations or referrals if needed. They should refer to colleagues when appropriate.
17. Good Medical Practice also says doctors should only prescribe drugs or treatment only when they have an adequate knowledge of the patient’s health and are satisfied the drugs or treatment will meet their needs. It says all patients have the right to be involved in decisions about their treatment and care and be supported to make informed decisions if they are able to.
18. The BNF is a reference book that gives clinicians advice about prescribing medication. It sets out the recommended dosage of specific drugs. The BNF includes a section explaining the ‘cautions’ and ‘side effects’ for different medicines.
19. The CKD Guideline does not relate to inpatient care and treatment. It explains how clinicians should manage patients who have CKD in the community. For patients with Mr A’s level of kidney function the CKD Guideline indicates there should have been follow up reviews every three months.
20. The Medical Adviser told us clinicians were aware from Mr A’s arrival at the Hospital that he had CKD and was ‘approaching dialysis.’ Mr A’s condition was stable, and the records show he could lie flat and was not breathless, so was not showing any signs of fluid overload. Doctors regularly monitored Mr A’s kidney function and planned for him to be seen as an outpatient following discharge. They involved kidney specialists in care planning.
21. By 21 October 2020 Mr A’s kidney function had worsened and doctors considered transferring him to the renal ward for dialysis. This did not happen because he tested positive for COVID-19. A doctor discussed this with Mr A who said he did not want dialysis unless it needed to be started urgently. The doctor said this was not the case at that point.
22. The doctor noted Mr A was then taking a high dose (600mg) of gabapentin (medicine to treat nervous pain or epilepsy) on his admission to the Hospital. They noted this should be reduced to 300mg because it accumulates in patients who have kidney failure. The doctor planned to keep Mr A in the Hospital until his renal function was more stable, but dialysis would be considered if renal function worsened.
23. On 23 October 2020 the clinical records show Mr A appeared to be much better. He no longer needed supplementary oxygen and his observations were all normal. The renal team were involved in assessing whether Mr A was well enough to go home. The doctors all considered he was fit for discharge. They noted he looked well and was moving independently. While Mr A still had signs of infection, doctors were treating this with antibiotics, and this could continue at home.
24. The Medical Adviser considered doctors followed Good Medical Practice. The doctors involved renal specialists and established that it was unnecessary for Mr A to stay in the Hospital. The clinical records were clear that Mr A no longer needed oxygen and so it was right that they did not provide him with this on discharge.
25. The Renal Adviser told us there were guidelines for managing kidney disease, but they did not relate specifically to Mr A’s situation. The main reasons for providing urgent dialysis to someone are usually severe hyperkalaemia (high levels of potassium) or pulmonary oedema (excessive fluid in the lungs). There is no evidence in the clinical records to suggest Mr A had either of these conditions. This means we can see nothing to suggest Mr A needed to stay in the Hospital for dialysis.
26. The clinical records show doctors spoke with Mr A about their plans to discharge him from the Hospital. When he first arrived at the Hospital the records show Mr A was confused. However, over the following days he had detailed conversations with doctors without any evidence of confusion. Nursing records also make no reference to any concerns about Mr A’s ability to understand what was being said.
27. We recognise Miss A considers her father would have been unable to retain information about follow up arrangements because of confusion. The Medical Adviser told us that doctors should be mindful of the Mental Capacity Act. This says doctors must assume someone has capacity to make decisions unless proven otherwise.
28. If there are concerns about confusion, doctors should carry out a capacity assessment to see if the patient has capacity to make that particular decision. There is nothing in the clinical records to suggest Mr A lacked capacity. Doctors were therefore right to communicate with him about his care in line with Good Medical Practice.
29. Miss A was also concerned about when doctors would have next reviewed her father. This is not documented in the clinical records. However, at the complaints meeting the renal consultant in attendance said she would have expected to see him again in around five days.
30. The Renal Adviser said, based on the CKD Guideline, the renal team should have reviewed Mr A within three months. However, based on his other conditions and ongoing illness, they are likely to have wanted to see him sooner. They would certainly not have been expected to see him within the next two or three days given he was considered well enough to leave the Hospital. We can only say the renal team intended to see him in less than three months. We find doctors did not fall below the standard expected in the CKD Guideline in this respect.
31. The Renal Adviser was concerned about the medication Mr A was taking at the time of his discharge from the Hospital. They considered the levels of medication doctors prescribed to Mr A to be excessive. The Renal Adviser questioned whether these could have had an effect on Mr A’s heart because the BNF lists heart block as a ‘caution’ for patients with Mr A’s kidney problems.
32. The BNF says the maximum dosage of atenolol (for high blood pressure or angina) for someone with Mr A’s kidney function should have been 50mg per day. It says the maximum dosage of diltiazem (also for high blood pressure or angina) should have been 300mg per day and for gabapentin the maximum should have been 300mg. The discharge letter from 26 October 2020 shows Mr A was prescribed 100mg of atenolol, 400mg of diltiazem and 600mg of gabapentin for each day.
33. The Renal Adviser told us doctors should have reviewed Mr A’s medication with a view to reducing the dosage before the discharge. We have referred above to a decision one doctor made to reduce the dosage of gabapentin, but the discharge letter still included a dosage of 600mg. The Renal Adviser suggested this could have contributed to Mr A’s confusion during the admission. However, it is impossible to establish whether this was the case. There is no evidence that consideration was given to reducing the levels of atenolol or diltiazem. Doctors did not follow the BNF.
34. We asked the Cardiology Adviser to explain whether the high dosage of medication had a detrimental effect on Mr A following his discharge from the Hospital. The Cardiology Adviser pointed out that Mr A was taking all three medicines at the same dosage before his arrival at the Hospital and he was stable at those levels.
35. The Cardiology Adviser said the appropriate monitoring for atenolol and diltiazem is blood pressure measurement and electrocardiograms (ECG – a test to measure the heart’s rhythm and electrical activity). These appeared to be stable throughout Mr A’s admission. The Cardiology Adviser considered this to be adequate monitoring of dosing above the licensed levels of the medication. They said it is very unlikely the dosage of these drugs led to any complications for Mr A. This is particularly the case when the levels of the drugs were long established.
36. We find that doctors followed Good Medical Practice when they discharged Mr A from the Hospital. They decided, appropriately, he did not need ongoing monitoring, supplementary oxygen, or dialysis at that stage. We also consider there was no requirement for a follow-up appointment in the days following Mr A’s discharge and we cannot say what happened in this respect fell below the CKD Guideline.
37. We consider doctors did not follow the BNF when they discharged Mr A from the Hospital with high levels of medication. But we cannot say this had any impact on his health.
38. We appreciate how shocking it must have been for Miss A and her family that Mr A died the day after he left the Hospital. We cannot say this was due to any failings by doctors at the Hospital. We do not uphold this part of Miss A’s complaint.
Complaint handling
39. Miss A told us the Trust took too long to respond to her complaint. She says this has caused her significant distress and has affected her mental health.
40. The Principles of Good Complaint Handling says public organisations should be ‘customer focussed’ when responding to complaints. This includes dealing with complaints promptly, avoiding unnecessary delay. It says organisations should keep the complainant regularly informed about progress and the reasons for any delays.
41. Miss A complained to the Trust by email on 2 August 2021 on behalf of her mother. A member of the Trust’s complaints team called Mrs A on 11 August to confirm receipt and noted the family had requested a meeting. On 22 September there was a further conversation which led to an agreement that the Trust would need to provide a written response before a meeting could take place. This was because of restrictions relating to access to the Hospital due to the COVID-19 pandemic.
42. Also, on 22 September 2021 the Trust acknowledged the complaint and confirmed it aimed to complete its investigation before 10 November.
43. The Trust replied in detail to the complaint on 9 November 2021. It noted the family had complained for the first time in early 2021 and had initially wanted a meeting. The Trust accepted it should have responded to the complaint quicker than it did. It said this had happened because of the pandemic. The Trust said this was below the standard expected and it apologised. It offered the family an opportunity to have a discussion with staff if they needed clarification.
44. On 22 February 2022 Miss A called the Trust. She asked for a meeting with relevant staff to discuss her complaint. We can see she contacted the complaints team again a week later to request an update.
45. On 21 March 2022 Miss A emailed us to complain about the Trust’s complaint handling. She said she contacted the Trust in November 2020, although her requests for information at that stage did not appear to be a complaint. She said she called the Trust many times over the following months and was ‘passed backwards and forwards’ because of staffing problems. Following the written response, she said she requested a face-to-face meeting, but this had yet to take place.
46. In June 2022 we asked the Trust to contact Miss A with a further response. The Trust advised us it was arranging a meeting but was having difficulty finding the appropriate staff to attend. Miss A contacted us, and we asked the Trust to respond several times over the following months. There were continued delays throughout this period.
47. Miss A and other members of her family attended a meeting with representatives from the Trust on 23 February 2023. The nursing director present at the meeting told the family it was ‘unacceptable’ they had needed to contact us to ensure the meeting took place. They apologised and explained how changes had been made to how the Trust handles complaints.
48. The Trust next wrote to Miss A on 13 July 2023. It said it could not add anything to its previous responses. It did not consider a further meeting would be beneficial.
49. We find the Trust did not deal with Miss A’s complaint promptly. The Trust has accepted there was a delay of several months when Miss A first complained. In addition, Miss A first requested a meeting in August 2021, and this did not take place for more than 18 months. The Trust appeared unaware of the distress the delays were causing for Miss A despite our involvement. There was then a further delay of over four months following the meeting before the Trust sent its final response. This was despite the Trust recognising its poor complaint handling and suggesting it had made changes to its processes.
50. We can see no evidence of the Trust contacting Miss A with updates and reasons for delays. The Trust was not ‘customer focussed’ when responding to complaints. The Trust fell below the standard expected in the Principles of Good Complaint Handling. Miss A is right to say the Trust took too long to respond to her complaint. We can see how distressing this would have been for her at a time when she was grieving. The Trust has also explained how, because of the time that has passed, it could not obtain explanations from the some of the clinicians who treated Mr A. Miss A has been left with unanswered questions.
51. We uphold this part of Miss A’s complaint.