Potassium levels
16. 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.
17. Mr L told us when the Trust discharged his mother it did not provide his family with safety netting around how to maintain her potassium levels. Mr L said the Trust also failed to provide his mother with take home potassium supplements.
18. The Trust told us it treated Mrs L with oral potassium supplements in October 2023. It said Mrs L’s potassium levels were normal for a week before her discharge. The Trust said it was not normal practice to discharge patients with normal potassium levels with potassium supplements.
19. NICE guidance says that older people are particularly susceptible to adverse effects of diuretics and that clinicians should monitor serum sodium and potassium levels. The guidance does not provide any specific information on how frequently these levels should be monitored.
20. GMC guidance says doctors must promptly provide investigations and treatment where necessary. It says to only prescription medications that serve a patient’s needs. It also says doctors must provide patients with information they require.
21. Medical records show the Trust admitted Mrs L on 9 October, at that time she had normal potassium levels. It noted Mrs L to be suffering from acute confusion and diarrhoea.
22. Records indicate Mrs L was taking bumetanide, a diuretic, for some time before the Trust admitted her. NICE guidance says loop diuretics, such as bumetanide, can cause an electrolyte imbalance. Electrolytes such as potassium and sodium are for crucial for the body’s processes such as nerve impulses and muscle contraction.
23. Records show the Trust paused Mrs L’s bumetanide on 10 October. The Trust paused this medication as it diagnosed Mrs L with delirium secondary to dehydration. A diuretic could make dehydration worse.
24. Medical records say the Trust first recorded Mrs L’s potassium levels to be low on 14 October, with her potassium listed as 3.4mmol/L. As we have seen in paragraph 10 Mrs L’s potassium results did not drop below 3.2mmol/L.
25. Local guidance says that a potassium level of 3.2mmol/L is mild hypokalaemia (low blood potassium). The guidance says if a patient has mild hypokalaemia and is taking digoxin (a medication to treat atrial fibrillation), potassium supplements should be provided.
26. The website GPnotebook says up to 50% of hospital inpatients with normal potassium levels on admission may develop hypokalaemia during their inpatient stays.
27. The records do not indicate what the Trust believed was the cause of Mrs L’s low potassium. Local guidance says common causes include the use of diuretics, diarrhoea or IV therapy with inadequate electrolyte replacement.
28. Mrs L appeared to be affected by most of these factors during her admission. As we have seen the Trust admitted Mrs L with diarrhoea and she had previously been taking diuretics. Records show that the Trust provided Mrs L with a sodium chloride IV drip in the evening of 13 October.
29. The records show Mrs L was taking digoxin at the time of her admission. The Trust provided Mrs L with oral potassium supplements in line with local guidance. Mrs L continued to have low potassium until 19 October when her bloods showed her potassium levels had returned to normal. Records show Mrs L’s potassium levels were normal until her discharge on 26 October.
30. Our adviser said there was no specific guidelines for providing potassium supplementation to patients on diuretics at discharge. They told us this would be based on the clinical judgement of the doctor.
31. We appreciate Mrs L may have been susceptible to low electrolytes due to her use of diuretics and her age, as noted in the NICE guidance.
32. We have seen Mrs L’s potassium levels were normal when the Trust admitted Mrs L to hospital. We have seen Mrs L went on to develop low blood potassium while an inpatient, which the Trust successfully treated before her discharge.
33. Considering the above we think clinicians have used clinical judgement to determine Mrs L did not require potassium supplements at discharge. In our view this decision was based on Mrs L being affected by several factors that can led to low potassium, while she was an inpatient. We have also seen Mrs L had normal potassium levels at admission and normal potassium levels for a week before discharge. This is likely to have been reassuring to the reviewing doctor.
34. We have seen no indications to suggest the Trust failed to follow GMC guidelines around providing treatment when appropriate for a patient. This is because we have seen no indications the Trust should have provided Mrs L potassium supplements at discharge.
35. We next considered whether the Trust should have provided specific safety netting advice about Mrs L’s potassium levels.
36. Our adviser said there was no specific safety netting guidance around potassium levels. They said it was not normal practice to provide specific safety-netting advice for patients on diuretics.
37. We can see the Trust have provided Mrs L with safety netting in the discharge letter. The Trust told her to return to her GP if she suffered from swelling of limbs or her abdomen. The letter does not include specific safety netting around the use of diuretics or maintaining potassium levels.
38. The discharge letter requested Mrs L’s GP complete a liver function blood test. It also discharged Mrs L’s care to her GP.
39. We appreciate NICE guidance suggests elderly patients taking diuretics should monitor sodium and potassium levels. In our view this would likely be completed in the community through a patient’s GP. Our adviser said in their experience monitoring would only be completed every few months.
40. Given the above we have seen no indications the Trust failed to provide Mrs L with safety-netting around her potassium levels. There is no indication the Trust failed to follow GMC guidance which says doctors must provide information patients need to know. We have seen the Trust has discharged Mrs L to her GP.
41. We appreciate Mrs L, despite help from her family, struggled when the Trust discharged her. We are deeply sorry Mrs L’s quality of life has suffered so significantly following these events. We wish Mrs L well in her recovery.