Inappropriate discharge
15. Miss A told us she believes her father was discharged inappropriately on multiple occasions. Miss A says his condition was worsening and he should have remained in hospital, or he should have been discharged to her home. She also felt his home environment was not safe and Trust staff failed to listen to her.
16. To address Miss A’s concerns, we asked our nurse adviser whether it appeared the Trust acted in line with national guidelines when discharging Mr A. Our nurse adviser told us the NMC ‘Code’ and the Department of Health & Social Care guidelines on hospital discharge and community support are applicable for this issue.
17. We can see Mr A was first admitted to the Trust on 10 October and remained there for four days with a suspected lower respiratory tract infection (LRTI). On admission, Trust staff asked Mr A about his home circumstances. Mr A told staff he lived in a bungalow with his partner, he did not have any support, by way of a package of care, at home.
18. We can see on 12 October, Trust staff assessed Mr A as having the capacity to make his own decisions. He was also assessed by physiotherapists (PT) who documented Mr A was independently mobile and there were ‘no mobility concerns’.
19. On 12 October the occupational therapy team also saw Mr A. Their role is to make sure patient discharges are carried out safely and are responsible for arranging care in the community if it is necessary. Mr A told the therapy team he had no concerns about going home, he declined any community support or equipment and stated his partner and daughter support him at home.
20. On 14 October, Mr A was considered medically fit for discharge by the doctors. PT assessed him again to ensure his discharge was safe and appropriate. We can see Miss A was unhappy the Trust were discharging her father. However, Mr A had capacity to be involved in his discharge planning and told staff he wanted to return home to his partner.
21. The NMC code states medical staff should ‘recognise and respect the contribution that people can make to their own health and wellbeing’, ‘encourage and empower people to share decisions about their treatment and care’ and ‘respect the level to which people receiving care want to be involved in decisions about their own health, wellbeing and care’. We can see the Trust involved Mr A in the decisions made about his care and treatment. It also respected his decision to return home on 14 October. This is in line with NMC guidance.
22. The Department for Health and Social Care (DHSC) ‘hospital discharge and community support guidance’ states Trusts should identify the best suited environment for patients and meet any ongoing health needs they may have. This includes arranging short term packages of care and recovery support in the community. It also states, ‘individuals should be discharged to the best place for them to continue recovery (if needed) in a safe, appropriate and timely way’.
23. On 31 October, Mr A was referred for community-based rehabilitation as he reported a decline in his energy levels during a home visit. This is rehabilitation care which is given to a patient outside of a hospital setting. The Trust put a care package in place for him. This included carers visiting Mr A three times a day to provide additional support for him and his partner. Our nursing adviser confirmed these actions were appropriate and in line with DHSC guidelines. It appears Trust staff arranged suitable ‘care and recovery support’ for Mr A whilst he was in the community.
24. During a home visit on 4 November, carers found Mr A had become more unwell and was admitted to hospital again. The notes indicate he had not been eating very well, he had a cough, low blood pressure and dizziness. PT’s reviewed Mr A again who noted his mobility had reduced as he was feeling weaker due to his shortness of breath.
25. Throughout this admission, discharge planning was ongoing in line with the NMC Code. We can see on 21 November, PT’s documented Mr A was ‘walking good’ and he was ‘eager to get home’. Mr A was scheduled to go home on 23 November with a new package of care, where carers would visit him twice a day. Prior to his planned discharge, a bed capacity manager spoke to him about his needs once he returned home. The bed capacity manager determined the package of care needed to be increased to four times a day, so his discharge was delayed until 28 November.
26. On 28 November, PT’s reviewed Mr A again and decided he required equipment at home to assist him once he was discharged. This delayed his discharge as the new equipment (bed, mattress and bedrails) needed to be delivered before he returned home. His discharge was rescheduled for 2 December. Our nursing adviser confirmed this shows the Trust took the correct steps to ensure his home and discharge were carried out safely. In line with DHSC guidelines, Trust staff made sure Mr A was discharged in a ‘safe, appropriate and timely way’.
27. The notes show ward staff informed Miss A of the planned discharge on 1 December. This is in line with the NMC Code which says nurses should ‘share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way, they can understand’. It appears Miss A was unhappy with the discharge arrangements. We have seen evidence at this time Mr A had the capacity to make decisions about his own care and it is noted he was ‘happy with discharge plans’.
28. In summary, Mr A’s discharge plans appear reasonable. Mr A wanted to go home and had the capacity to make that decision. PT, occupational therapy and nursing staff were involved in discharge planning to ensure Mr A received the care and equipment he needed on discharge. His discharge plans were discussed with his partner and daughter with Mr A’s consent, and the Trust took steps to ensure his home environment was safe.
29. We appreciate Miss A was concerned about her father’s situation at home and felt he should have remained in hospital. We recognise it was distressing and upsetting for her to think her father was unsafe. Understandably, Miss A was concerned about his wellbeing, and we do not wish to underestimate or dismiss what a stressful experience this was for her.
30. The evidence we have seen surrounding Mr A’s discharge indicates the Trust acted in line with the NMC Code and the DHSC guidelines by respecting Mr A’s contribution to his care and respecting his right to accept treatment at home. We hope this reassures Miss A his care does not appear to fall below the standard expected. We will not be taking any further action on this issue.
Fall:
31. Mr A was an inpatient at the Trust from 8 December until 20 December when he died. On 16 December Mr A had an unwitnessed fall during the night. Very sadly, he sustained injuries to his face. Miss A believes the Trust failed in its duty of care to Mr A for allowing this fall to happen. She also says Trust staff did not make her aware how severe the fall was.
32. It must have been very shocking and upsetting for Miss A to later find out her father had sustained injuries to his face from a fall in hospital. We appreciate this would have caused her significant worry that his safety had been compromised when he was already unwell. We are very sorry to hear of the added distress this caused.
33. We asked our nurse adviser whether the Trust did enough to prevent Mr A from falling.
34. Our nurse adviser explained it is difficult to put measures in place to completely prevent a patient from falling in hospital. According to the NAIF report, even with appropriate safety interventions, the risk of falling is reduced only by 20-30%. The risk of falling cannot be completely removed.
35. That said, our nurse adviser explained it is a nurse’s duty to balance the patient’s safety whilst upholding their dignity and privacy. This is in line with the NMC Code. It states nurses should ‘respect a person’s right to privacy in all aspects of their care’ and take steps to ‘promote the wellbeing’ of patients in all stages of their care.
36. NICE CG161 says older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year.
37. Additionally NICE CG161 says an appropriate ‘health care professional’ should carry out a ‘multi factorial falls risk assessment’. This risk assessment helps staff create an individual falls prevention plan, to put appropriate measures in place to prevent falls from happening.
38. On 10 December, the records show Trust staff correctly completed a ‘fall risk and bed rail assessment’ with Mr A. This is in line with the above NICE CG161 guidelines.
39. In this assessment, nursing staff documented Mr A required bedrails as he needed the assistance of one person to get out of bed and move around. They also documented he was not confused and could use his call bell to ask for assistance when required. The assessment deemed him as being ‘at risk of a fall’ but not high risk. He was placed on two hourly rounds (this is when a staff member checks his wellbeing at least every two hours).
40. Our nursing adviser confirmed this falls assessment was correctly completed and thoroughly considered Mr A’s needs in line with NICE CG61 guidelines.
41. The records indicate Mr A had begun getting ‘intermittently confused’ on 15 December. However, importantly, Mr A appeared to still be aware of how to keep himself safe. He did not attempt to get out of bed by himself, and there was no indication his two hourly rounds needed increasing to ensure his safety. Our nurse adviser confirmed she would not have expected Trust staff to have put any other measures in place at this time to prevent him from falling.
42. Mr A was in bed asleep before his fall. At around 3.40am, he woke up and appeared to have tried to climb out of bed. Sadly, he fell onto his face and sustained a cut to his left upper eyelid. Following a CT scan, he was found to have multiple facial fractures.
43. Our nurse adviser confirmed sadly, this fall could not have been anticipated. Mr A was sleeping prior to his fall and had no history of attempting to get out of bed by himself.
44. In summary, it is very unfortunate Mr A fell out of bed during the night. We don’t wish to diminish in anyway how upsetting this would have been for him and Miss A. Having carefully reviewed the evidence; it appears Trust staff correctly completed a falls risk assessment and put appropriate measures in place to prevent him from falling. This is in line with NICE CG161 guidelines. Our nursing adviser confirmed it would not have been appropriate to place any further restrictions on Mr A, as it was important to also uphold his dignity and privacy in line with NMC guidelines. Taking all this into account, we have seen no indications of failings here.
45. Miss A told us the Trust failed to inform her of the severity of his injuries and told her ‘these things happen, it wasn’t as bad as it looked’. She says when she visited him after his fall she was ‘devastated’ and ‘still has nightmares about his appearance’.
46. We can see a deputy ward sister called Miss A at around 11am on 16 December to discuss her father’s fall. The sister reassured Miss A he had a CT scan and had been monitored for any deterioration in his condition. A doctor called her at around 5pm to inform her they were still waiting for the results of the CT scan.
47. The records indicate the results became available at 7.30pm. A doctor documented a conversation with Miss A at 7.45pm. They informed her of the scan results and the plan to treat Mr A’s injuries. Staff have documented a further telephone call with Miss A on 17 December at 8pm, giving Miss A an update about his condition.
48. GMC Good Medical Practice, 31 says: ‘you must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.’ On review, we can see Trust staff acted in line with this guidance. It appears they promptly informed Miss A of her father’s condition as and when the information became available.
49. We can appreciate how distressing this experience was for Miss A being away from her father when he had sustained an injury. We do not wish to underestimate the long-lasting impact her last image of her dad was.
50. From what we have seen, we consider Trust staff took appropriate steps to explain what had happened and regularly update her about her father’s condition following the fall. This is in line with GMC guidelines. For this reason, we have decided not to investigate this complaint further.
Oxygen therapy
51. Miss A told us the Trust did not give Mr A oxygen therapy at the right time. Mr A returned to the Trust on 8 December with possible malnutrition, community acquired pneumonia, a LRTI and possible type two respiratory failure.
52. On admission to A&E, Mr A was receiving one litre of oxygen, and his oxygen saturations are documented to be around 98%.
53. The BNF ‘Oxygen’ guidelines explain the normal range for oxygen saturations is around 94% to 98%. However, in some situations a lower target of 88% to 92% is acceptable for patients at risk of type two respiratory failure.
54. The A&E doctor determined Mr A’s oxygen saturations should be at the lower level as he was at risk of developing type two respiratory failure. Further, Mr A’s recent blood tests had shown he was also showing signs of chronic CO2 retention.
55. CO2 retention deprives your body of oxygen which can cause serious health problems like severe hypercapnia (this is when you have too much carbon dioxide in your blood), which may lead to respiratory failure and sometimes death.
56. NLM guidance says respiratory failure is a common complication in the advanced stages of ILD. To manage this, oxygen therapy should be administered according to the severity of the patient’s respiratory failure. Our consultant adviser explained as Mr A had a history of ILD and was showing signs of respiratory failure, the decision to stop administering oxygen and aim to keep his oxygen saturations between 88% to 92% was appropriate.
57. Sadly, Mr A’s condition deteriorated during this admission. Miss A believes her father should have been given oxygen therapy throughout this admission. We hope to reassure her we have seen no indications the A&E doctor’s decision to stop her father’s oxygen therapy was inappropriate on 8 December.
58. On 18 December, Mr A’s CRP (C-reactive protein is produced by the liver and high levels sometimes indicate inflammation) and white blood cell count were raised on his blood test results. Our consultant adviser told us this usually indicates an infection. A consultant microbiologist (a clinician who provides advice on infectious diseases and treatment options) advised doctors treating Mr A to continue prescribing him the antibiotics he was already taking for the LRTI.
59. At 1.10am on 19 December, we can see from the observation chart, Trust staff restarted Mr A on oxygen. There is nothing documented in the records at this time, to explain the reasons for this. The Trust’s internal investigation report (IIR) acknowledges there is a lack of documentation from this time. It explains the reason he was restarted on oxygen, was likely verbally communicated to nursing staff at the time.
60. We looked at whether there was any other evidence in the records, to explain the reasons why Mr A’s oxygen was restarted. There is a note from a doctor at 11.19am on 19 December, recording Mr A’s oxygen saturations as being 67% without oxygen. Our consultant adviser confirmed this falls outside of the BNF target range. Therefore, the Trust’s decision to restart Mr A’s oxygen earlier this day, at 1.10am, appears to be clinically appropriate.
61. At 4.15pm, the respiratory consultant reviewed Mr A. The consultant said he needed an urgent chest X-ray, new antibiotic treatment (for the new infection), increased oxygen therapy and further blood tests.
62. Our consultant adviser reviewed the blood test results from this time. They told us the arterial blood gas (ABG) taken at 4pm appears to be normal. There are signs of a ‘modestly raised CO2’ levels but they remain the same as they were when he was admitted to hospital. On this basis, our consultant adviser confirmed Mr A’s oxygen therapy appears to have been effective at maintaining his oxygen levels.
63. Mr A appeared to remain stable throughout the afternoon and evening with oxygen saturations of around 96% on oxygen. Unfortunately, at 1.30am on 20 December, Mr A’s condition drastically deteriorated and he was found unresponsive. Mr A had a DNACPR (no not attempt CPR, means you do not receive CPR if your heart stops) in place and was for ward based care only.
64. We can see nursing staff made emergency calls at 1.40am and 1.50am and the relevant crisis teams attended to Mr A. Further tests were carried out and Mr A’s oxygen therapy was increased to 15 litres. Sadly, Mr A died at 2.49am.
65. Our consultant adviser has reviewed the medical records. They explained with Mr A’s pre-existing health conditions and gradual decline over the preceding months, it is unlikely any other additional treatment would have been available to prevent his death. Sadly, Mr A developed another infection on 18 December and his condition rapidly deteriorated. Our adviser was satisfied Trust staff followed BNF guidelines when making decisions about giving Mr A oxygen therapy. We hope this reassures Miss A we have seen no failings for this aspect of the complaint.
Conclusion
66. Overall, we have not seen any failings directly leading to Mr A’s death. We can see the Trust acted in line with the relevant guidelines when discharging Mr A and trying to keep him safe from falling. We also did not see any indications it missed an opportunity to give Mr A oxygen at an earlier time.
67. We appreciate how distressing this experience was for Miss A and do not wish to diminish the impact it has had on her. We recognise Miss A believes the Trust failed to give her father oxygen and feels if it did, he may not have deteriorated so soon. Ultimately, the Trust acted appropriately by not giving Mr A oxygen until his health deteriorated on 19 December.
68. We hope this statement goes some way to reassuring Miss A her concerns have been thoroughly investigated and the Trust could not have done any more to prevent Mr A’s death.