Communication
26. Ms A complains that a doctor from the Trust was unhelpful and belligerent when she called for an explanation regarding her father’s discharge from hospital in June 2022.
27. The Trust has already acknowledged and apologised for this. It explained that this doctor no longer works for the Trust and so it cannot speak with them to ascertain what happened.
28. We cannot know exactly what was said and how it was said on this call. We can see the Trust has apologised for this and, as this appears to be a one-off instance of poor service, there is nothing further we could reasonably ask the Trust to do to put things right.
29. An apology is recommended by our Severity of Injustice Scale as being appropriate to put right a one-off instance of poor service. For this reason, we are taking no further action on this aspect of Ms A’s complaint.
Investigations
30. Ms A is concerned that the Trust failed to investigate the cause of the fluid on her father’s lungs during his hospital admission from 18 April 2022.
31. The British Thoracic Society’s published guidelines on pleural diseases provides a diagnostic algorithm for a diagnosing and treating pleural effusions. These guidelines say that, in the first instance, if doctors suspect a pleural effusion, they should undertake a chest X-ray. This happened on 18 April and the results of the chest X-ray showed no signs of fluid on Mr B’s lungs. The radiological advice was to repeat this test in six-weeks’ time.
32. At this stage, the medical evidence indicates Mr B did not have fluid on his lungs and was being treated for suspected pneumonia. He did appear, however, to be retaining fluid due to his heart failure. The doctors planned to treat the heart failure and associated fluid retention, and then consider further tests if there was no improvement.
33. The Trust’s physicians further examined Mr B on 27 April and 2 May, and noted his lungs sounded clear. This indicated there was no fluid present on the lungs at that time and there was no requirement to investigate this further. Section 15 of the GMC’s Good Medical Practice guidelines states that doctors should provide appropriate investigations when necessary. It is not ethical for doctors to undertake tests when they are not clinically indicated, and so it appears appropriate that they did not investigate this further.
34. Ms A is also concerned that the Trust failed to drain fluid from her father’s lungs in June, dismissed his symptoms, and delayed in undertaking a scan in July.
35. When Mr B was admitted to hospital on 3 June, he had a chest X-ray and was diagnosed with a pleural effusion. The X-ray was not clear and so a CT scan was undertaken to confirm the effusion, which was completed on 6 June. The Trust then drained a sample of fluid for testing on 9 June. This appears to align with the process recommended by the British Thoracic Society guidelines. These guidelines only recommend draining the fluid therapeutically when a patient’s symptoms require it. Our adviser told us it was appropriate not to drain the fluid at this stage.
36. Mr B had a chest X-ray when re-admitted to hospital on 23 June. This X-ray confirmed the continued presence of a large pleural effusion. The Trust then undertook a therapeutic pleural tap two days later. This involved draining 1100ml of fluid to help relieve Mr B’s breathlessness.
37. The reason why the doctors had to wait until 25 June to drain this fluid was because Mr B was taking a drug called rivaroxaban to manage his heart condition. This drug makes any invasive procedure more dangerous because it increases the risk of uncontrolled bleeding. Because of this, the doctors withheld this medication for 48 hours and then drained the fluid.
38. Withholding this medication posed risks to Mr B’s heart function, but not draining the fluid was causing him to feel breathless. He had already had this medication withheld when he had the diagnostic tap. It was appropriate to balance the risk of uncontrolled bleeding and cardiac complications when Mr B’s breathlessness was less symptomatic. This is also in line with the guidelines from the British Thoracic Society.
39. Following this drain, Mr B reported feeling better. A chest X-ray after the procedure confirmed that the fluid had been successfully drained off and a further chest X-ray on 11 July showed that the fluid had not come back.
40. On the 19 July the TB result on the pleural fluid came back positive and appropriate antibiotics were started.
41. On the 24 July Mr B complained of pain, first in his ribs then his abdomen. The doctors could not find a cause for this pain when physically examining Mr B, and so requested a CT scan of his abdomen on 26 July. Three days later, it also requested a CT scan of Mr B’s head due to drowsiness. These scans were requested because Mr B had new, unexplained symptoms.
42. The doctors appear to have promptly and appropriately responded to Mr B’s symptoms, and clearly documented discussions with him about the investigations and treatment being provided. These notes included Mr B’s perspective on how he was feeling at that time.
43. The evidence indicates the prior to 24 July there was no clinical indication for further scans. The chest X-rays were undertaken to monitor his pleural effusion, and a CT scan was not required until Mr B had further, unexplained symptoms. The evidence also indicates that when Mr B reported symptoms, the doctors acted on these promptly. Because of this there is no indication that the Trust delayed in undertaking a scan or dismissed Mr B’s symptoms.
44. Ms A also complains that Trust delayed in investigating whether there was an infective cause for her father’s symptoms.
45. Mr B’s medical records show that from his admissions in April the doctors suspected an infection of the lungs and treated Mr B with antibiotics. They also, initially, treated Mr B for heart failure because the doctors felt this may have been the primary cause of his symptoms.
46. When Mr B developed a pleural effusion, and the treatment for heart failure did not address this, the Trust commenced further investigations. It undertook investigations for an infective cause, as well as consulting the specialist lung cancer team in case this was an unusual presentation of lung cancer. The Trust sent the sample for potential infective causes on 9 June.
47. Mr B’s sample was tested for a number of infective agents and, ultimately, he tested positive for TB. TB is caused by a type of bacteria and the only way to definitively confirm TB infection is to test a clinical sample. When a sample goes to a laboratory, the lab must culture the different samples to see what (if any) pathogens may grow. Different types of bacteria grow at different rates, and this affects how long takes to confirm a sample is positive for certain types of bacteria. The time it takes a bacteria sample to culture depends on how quickly that type of bacteria divides and multiples.
48. The type of bacterium which causes TB grows incredibly slowly when compared to others. For example, e-coli bacteria divide once every 20 minutes, whereas the bacteria causing TB divide once per 18-24 hours. This means that it takes much longer for a positive sample to be cultured. It typically takes four to six weeks to confirm TB infection, compared to days for most other bacterial samples. We understand why this might appear to be an unreasonable delay, but this is the standard and expected time it takes to confirm whether or not a sample contains TB.
49. The evidence indicates that the Trust’s doctors acted in line with the British Thoracic Society and GMC’s guidance by arranging for timely investigations, including sending pleural samples to test for an infective cause. Unfortunately, the type of infection Mr B had was one that takes several weeks to receive the results for, which may have appeared to be an unreasonable delay. The sample was taken promptly, and once TB was confirmed, the doctors promptly commenced the appropriate treatment.
50. Overall, we have seen no indication the Trust failed to or delayed in investigating an infective cause for Mr B’s symptoms.
Hospital discharge
51. Ms A is very concerned about the Trust’s decisions to discharge her father from hospital. She specifically complains that it:
• discharged her father from hospital on 9 May 2022 when he was not medically well enough to go home • failed to discuss her father’s discharge from hospital in May 2022 with his family • did not arrange for an ambulance to transport her father home when discharged in May 2022 and, instead, arranged a taxi and sent him home without his walking aid • discharged him from hospital in June 2022 when he was not medically well enough and had vomited that morning.
52. NHS England has published guidelines for discharge from acute hospital settings which apply to Mr B’s care. These guidelines state:
• planning discharge should respect people’s individual choices, and if the patient’s view differs from their family’s their right to make this choice should be respected • where appropriate, family members should be involved in discharge decisions.
53. This guidance also provides clinical criteria for when a person should not be considered for discharge from an acute setting. These are set out in Annex D of the guidelines.
54. Mr B’s medical records show that, as of 3 May, the only clinical concerns that had not been treated were concerns about his swallowing and his low mood. The plan was to ask the MHLT and the gastroenterology team to review him before considering discharge home.
55. He was reviewed by the gastroenterology team on 4 May and the MHLT on 6 May. The notes made by the MHLT indicate that Mr B felt his mood was low because he was in hospital and that he anticipated it would improve if he could go home. The MHLT recommended continuing with discharge planning as his mental health concerns could be managed by his GP.
56. On 9 May the consultant noted Mr B was medically fit for discharge and documented that he reported ‘feeling much better and [was] very keen to go home’.
57. On 10 May a doctor documented a long and detailed conversation with Mr B’s family, prior to his discharge later that day. The doctor documented addressing several concerns and that the family agreed to the discharge.
58. Later that evening the family contacted the hospital to say Mr B looked unwell when he got home and the family were concerned about this.
59. Based on the medical evidence available, Mr B appears to have been medically fit for discharge when he discharged on 10 May. It appears to have been his preference to go home because being in hospital was making him feel depressed. This discharge appears to have been fully discussed with and agreed by Mr B’s family, and he did not meet the criteria for remaining in acute hospital care. This appears to be in line with the guidance published by NHS England.
60. We do not doubt that Mr B looked unwell when he was discharged home. He was quite an unwell man at that time, though these were not illnesses that could not be managed in the community. We understand that this could have caused his family concern, and that families often think the best place for someone who is unwell is a hospital. In reality, for someone as vulnerable as Mr B, a prolonged hospital admission may have been detrimental to his health, and it appears appropriate that he was discharged home once his acute medical needs had been addressed.
61. With regards to the complaint that the Trust sent Mr B home in a taxi and without his walking aid, it is difficult to ascertain precisely what happened from the medical records, though the Trust’s complaint response adds some additional context.
62. Mr B’s medical records indicate an ambulance was booked, including a booking reference number for the ambulance, and a member of staff retained to escort him home. The Trust’s complaint response then indicates that North West Ambulance Service was experiencing lengthy delays at that time, meaning Mr B would likely have had to wait several hours to go home if he waited for an ambulance. A nurse risk-assessed him and decided it was safe for him to go home in a taxi with an escort. The Trust cannot account for what happened to his walking aid.
63. The Trust apologised for the confusion and miscommunication around this, and this appears to be sufficient to put right the impact of what may have gone wrong. It also said that it offered to replace the walking aid on 11 May, but that the family declined this. It apologised for what happened with the walking aid. This is in line with what we would likely have asked the Trust to do, and so we are not taking further action.
64. With regards to the discharge in June 2022, Ms A is concerned that her father was not medically well enough to go home because he had vomited that morning.
65. There is no record of Mr B vomiting in his medical records. This does not mean this did not happen, but it does mean we have no contemporaneous evidence that it did.
66. Mr B’s medical records indicate that the only outstanding acute issue as of 22 June was his pleural effusion. The clinicians had taken advice from the Trust’s lung cancer team, which advised that his care could be managed by the outpatient pleural clinic. All other clinical indicators showed Mr B appeared to be medically stable and he did not meet NHS England’s criteria for remaining in an acute hospital setting.
67. We understand that Mr B was readmitted to hospital the following day, and that this would understandably cause his family concern that he had been inappropriately discharged. Deciding when to discharge a patient involves carefully considering the risks associated with a delayed discharge, which can increase the risk of mortality from hospital-acquired infections, as well as the risks posed by going home. It is not unusual for a patient to be medically fit for discharge, but to deteriorate once back in the community and require readmission. This can be due to avoidable factors, but it is also commonly due to unforeseen circumstances.
68. With hindsight, it may have been better if Mr B had remained in hospital; however, the doctors at the time could only rely on the medical evidence they had. This indicated Mr B was stable and did not meet the criteria to remain in hospital. They also had to bear in mind that the longer he stayed in hospital, the more exposed he would be to hospital-related risks. This is a difficult balance to achieve with vulnerable patients.
69. On balance, the evidence indicates there were no further acute medical needs on 22 June that could not be managed in the community and his discharge appears to align with NHS England’s guidance on hospital discharge.
70. We recognise that these months must have been incredibly distressing for Ms A and her family. They had recently lost their mother, Mr B’s wife, and Mr B’s condition deteriorated steadily over a number of months. We hope this independent review helps to reassure Ms A that the care her father received appears to align with national guidelines. This does not mean the experience of losing her father was not a difficult and traumatic one, but it does indicate the care he received was appropriate to his needs in the final months of his life.