University Hospitals Birmingham NHS Foundation Trust

4. Miss R complains about the Trust’s decision to discharge her mother, Ms R, on 17 March 2022. Miss R says her mother’s discharge home was unsafe considering she remained so unwell, and instead of arranging an outpatient colonoscopy, the Trust should have kept her in hospital and performed this without delay.

5. Very sadly, Ms R collapsed at home on 18 March, where she aspirated on her vomit. She was readmitted and she sadly died at the Trust on 23 March 2022. Miss R says if the Trust had kept her mother in hospital and performed the colonoscopy, she would have received the ongoing care and treatment she needed, signs would have been seen, and she would not have suffered the events at home that caused her a distressing and painful death from sepsis. Miss R considers her mother’s death avoidable and a direct result of the Trust’s decision to discharge her home.

6. Miss R says she has been diagnosed with post-traumatic stress disorder, anxiety and depression having witnessed her mother’s suffering. She says these events have had a significant emotional toll on her and the whole family.

7. To resolve her complaint, Miss R would like the Trust to acknowledge its failings and apologise for their impact. She also seeks a financial payment, in recognition of the impact caused by these failings.

8. Ms R arrived at the Trust’s emergency department (ED) on the evening of 7 March 2022 with abdominal pain. Records note this pain had started the previous day, and she reported over 10 episodes of fresh blood-stained vomiting and loose stools with no blood.

9. Records note Ms R had episodes like this previously, most recently three weeks previously. It was noted she would have frequent flare-ups of gastroparesis (a delay of the stomach in emptying) and would often experience diabetic ketoacidosis (a serious complication of diabetes) afterwards.

10. Ms R’s past medical history included pancreatic enzyme insufficiency (causing a difficulty to properly digest food) and gastroparesis. She had Type 1 diabetes, chronic kidney disease stage 4 (CKD, at a stage considered severe and irreversible), anaemia (low iron due to chronic disease, primarily her CKD), hypertension (high blood pressure) and depression.

11. Ms R also had peripheral vascular disease (PVD) and vascular calcification (both of which result in a hardening and narrowing of the arteries, leading to reduced blood flow). She had peripheral neuropathy (damage to the nerves) and diabetic retinopathy (damage to the retina within the eye), and chronic diarrhoea.

12. Following her attendance to the ED on 7 March 2022, Ms R was admitted onto a ward. She was given intravenous (IV) fluids, IV antiemetics (anti-sickness medication), IV proton pump inhibitors (medication to reduce stomach acid) and IV paracetamol, with regular long-acting insulin.

13. At the ward round on 12 March, Miss R told staff she felt her mother was not recovering as normal, and Ms R reported feeling sick and experiencing headaches. The Trust took a CT head scan, which reported no acute intracranial pathology (no immediate, urgent or new issues within the brain).

14. By 13 March, records note Ms R’s DKA had resolved, yet there was new concern about a possible hypertensive crisis (a severe increase in blood pressure). A CT scan of the thorax, abdomen and pelvis was requested and reported possible pancolitis (inflammation of the colon). A gastroenterology opinion was requested and after discussion on 15 March, the gastroenterologist confirmed the radiological (from imaging) diagnosis of pancolitis.

15. The gastroenterologist advised a test of Ms R’s faecal calprotectin (a type of protein which, when found in stool, indicates the gut is inflamed). They advised that if the faecal calprotectin was normal then no further investigation was needed, and if it was raised, Ms R should be scheduled for an outpatient colonoscopy.

16. That same day, an echocardiogram was taken (to look at the structure and function of the heart), reporting as normal. Discussion with the cardiology team concluded as there were no clinical signs of heart failure, and Ms R’s raise blood pressure was more likely due to her CKD.

17. The faecal calprotectin test was given to Ms R on 16 March and at the last ward round on the morning of 17 March, records note it was explained to Ms R how she could submit the sample once home and contact her GP if she did not hear about the result. The plan was for her discharge, and an entry at 1.37pm notes she left the department with her daughter.

18. On the evening of 18 March Ms R collapsed at home. She was taken to the ED by ambulance, arriving at 1.20am on 19 March. Records note she had been found unconscious with a low blood pressure, abdominal distension, having had multiple episodes of vomiting and passing blood in her stool. At the Trust, surgical review took place and queried an upper gastrointestinal bleed, requesting a further CT scan of the abdomen, thorax and pelvis.

19. This found a significantly distended large bowel with associated gaseous distension of the ileum (the final and longest segment of the small intestine), and appearances in keeping with a bowel obstruction secondary to faecal loading (also known as impaction, a build-up of stool). At this time Ms R was being cared for in the intensive treatment unit, where she was intubated (put onto a machine to help her breathe).

20. A flexible sigmoidoscopy was performed (where a camera and light on the end of a flexible tube is inserted to look inside the rectum and lower colon). This found ischaemic colitis (inflammation of the colon, ‘ischemia’ meaning a restricted blood flow), however the camera could not pass higher due to the faeces. The Trust performed an emergency laparotomy (a surgical procedure to look inside) and this enabled surgeons to decompress the distended colon.

21. Records show Ms R remained unwell, with ongoing blood loss from the abdominal opening, and persistently high vasopressor needs (medication to raise blood pressure). Sadly, Ms R developed multi-organ failure, she was too unwell for a re-look laparotomy and the decision was made to withdraw organ support.

22. Ms R died on 23 March 2022. The cause of her death is recorded as multiorgan failure, caused by sepsis, caused by the ischemic bowel. Type 1 diabetes with end organ damage are listed as other contributory conditions.

23. Remaining unhappy with the responses to her complaint, Miss R asked us to investigate.

27. We know how concerned Miss R is about the Trust’s decision to discharge her mother home on 17 March. We hope to assure her we find the Trust followed the relevant guidance and we do not see any evidence of service failure with this decision.

28. We find from the recorded evidence that in the days leading up to discharge, Ms R appeared well. At the ward round on 15 March, it is noted Ms R was seen in the presence of her daughter, that she looked comfortable lying on the bed, was fully alert, speaking in full sentences with normal heart sounds, no chest crackles, a soft abdomen and bowel sounds present (the noises made by the intestines during digestion).

29. At the ward round on 16 March similar positive clinical findings are noted, and there was no documented report of any concerns. On 17 March, shortly before she left for home, it is noted Ms R was sitting comfortably on the bed.

30. On all three of these days Ms R’s NEWS was 0, with just one measure of 2 prior to discharge. NEWS stands for the National Early Warning Score. It is a system used nationally to improve the detection and response to clinical deterioration in adult patients. Six physiological measurements are taken of the person’s pulse rate, blood pressure, breathing rate, temperature, oxygen level and level of consciousness, and each are given a score. In line with NEWS2 guidance, a NEWS of 0 indicates all parameters are within the normal range, with a 2 indicating only a low clinical risk. As our adviser explains, indicates the patient is well considering observations alone.

31. Alongside her ward-based care, Ms R was reviewed by both a gastroenterologist and a cardiologist on 15 March, neither of whom appeared to have concerns. Blood results on 15 March were also completely normal, with C-reactive protein levels at less than 1. Known as CRP, this is a marker in the blood tested to look for inflammation or infection, with a normal CRP level considered at less than 3 for most people without underlying conditions. Also on 15 March, the echocardiogram reported completely normal findings of the heart.

32. We acknowledge Miss R considered her mother too unwell for discharge. We recognise she knew her mother best, and we in no way underestimate that Ms R had recently been unwell to the point of needing several attendances at hospital, including this one. In the days leading up to this discharge specifically, recorded entries do not suggest Ms R was so unwell at the point she returned home.

33. DoH guidance on safe hospital discharge contains specific criteria that should be met before a patient is sent home. The guidance says if the answer to each criteria is ‘no’, then active consideration for discharge must be made. The criteria questions are as follows:

• requiring intensive or high dependency care?

• requiring oxygen therapy or non-invasive ventilation?

• requiring intravenous fluids?

• NEWS2 greater than 3?

• diminished level of consciousness where recovery is realistic?

• acute functional impairment in excess of home or community care provision?

• last hours of life?

• requiring intravenous medication greater than twice a day (including analgesia)?

• undergone lower limb surgery within 48 hours?

• undergone thorax-abdominal/pelvic surgery with 72 hours?

• within 24 hours of an invasive procedure? (with attendant risk of acute life-threatening deterioration).

34. As we can see from the records and our adviser confirms, in Ms R’s case the answer to each of the above was ‘no’ for a number of days leading up to discharge. She therefore did not meet any of the criteria that would have precluded her from discharge on 17 March 2022.

35. DoH guidance acknowledges that clinical exceptions to the criteria will occur, stating this must be warranted and justified. Our adviser does not find any apparent reason to make a clinical exception in Ms R’s case. The ward round entries noting observation and examination findings, along with blood results, other investigations and specialty input all suggested Ms R was stable and had improved.

36. We recognise Miss R had various concerns about the discharge being unsafe, explaining her mother was still not eating or drinking, needed assistance with daily living activities and her blood pressure was volatile. In terms of eating and drinking, our adviser explains this alone does not mean someone cannot be discharged. Our adviser explains patients often eat better at home with their usual diet, rather than with hospital food. There is nothing to document Ms R was vomiting or not able to eat for any reason that would have required her to remain in hospital.

37. Regarding the concern about her daily living, we do not find any entry to support Miss R’s concern. A much earlier occupational therapy (OT) review on 9 March documented Ms R lived with her husband, that she was normally independent with mobility using one walking stick around the house and she was independent with her personal care. Ms R reported her husband would complete all domestic activities of daily living, listed as shopping, meal preparation, cooking etc. We cannot see that this would have changed by the point of her discharge home.

38. We also find an entry on 10 March noting discussion with Miss R who said she was her mother’s main carer, supporting her with daily living activities, and she would be happy to provide support on discharge. Ms R was witnessed mobilising independently to and from the bathroom that day, with encouragement. This was almost 8 days prior to discharge when she was in a poorer clinical condition.

39. Our adviser says even had Ms R been unable to self-care at that later point in time when better, this does not necessarily mean she was not medically fit for discharge. In any event, assurance had already been given by Miss R that she would provide support on discharge and Ms R lived with her husband who provided support with daily living.

40. Miss R raised concerns of her mother’s volatile blood pressure, which we interpret to mean that it was going up and down. Our adviser says this is not, of itself, something that would keep a person in hospital. If a patient is not having a hypertensive emergency – which would involve a severe increase in blood pressure, characterised by symptoms such as chest pain, severe headache, or dizziness, and often accompanied by organ damage – then blood pressure is best managed by their own GP. This would include if blood pressure is going up and down.

41. Ms R’s past medical history included hypertension. Our adviser explains that essential hypertension, the medical condition characterised by elevated blood pressure levels without an identifiable cause, is best managed by GPs who can take blood pressure readings in the calmer environment of a GP practice and prescribe the tablets to treat as necessary.

42. Our adviser explains a person’s blood pressure may be up and down for many reasons, such as pain, dehydration, stress, anxiety, to name just a few. Of itself, it does not require a person to remain in hospital or mean their discharge was inappropriate on this basis. We add, that as explained, Ms R’s NEWS was 0 in the days leading up to and on the day of her discharge, with one score of 2 prior to discharge. The score of 2 on this occasion was not due to her blood pressure. This indicates that in those days Ms R’s blood pressure was stable and at a normal level.

43. Lastly, Miss R considered her mother should have been kept in hospital for colonoscopy and had this performed without delay. When the gastroenterologist considered Ms R’s case including her recent CT scan on 15 March, they advised a faecal calprotectin test first. They advised only if results of this were raised, to then arrange colonoscopy on an outpatient basis. There was nothing clinically to suggest any urgency with either test.

44. The faecal calprotectin was given with instruction for Ms R to complete at home. Even had it been done before Ms R’s discharge, we cannot know whether results would have been raised to have warranted colonoscopy. If not, colonoscopy on either an inpatient or outpatient basis would not have been clinically indicated. Even had the result been raised and known before discharge, the specialist advice remained for an outpatient, not an inpatient colonoscopy. This was not sufficient reason for Ms R to have remained in hospital nor required as a test as an inpatient, at that time.

In conclusion 45. We very much recognise the reasons for Miss R’s concern. We now know, Ms R went from being well at discharge to being extremely unwell, requiring readmission, and that she very sadly then died. From the records we have seen, there was nothing at the point of discharge to suggest she needed to remain in an acute inpatient environment. Our adviser confirms there was nothing at the point of discharge to suggest she was unwell or would become so unwell.

46. Our adviser explains Ms R was diagnosed with ischaemic bowel following her readmission in the early hours of 19 March. This is not something she had before discharge and is something that is variable in its onset, from mild and slowly evolving, to acute, very sudden and severe, as is sadly what happened in Ms R’s case.

47. We extend our condolences to Miss R, and we are very sorry for her loss. We hope our explanations go some way to providing assurance that the decision to discharge was appropriate and in line with guidance. Very sadly, subsequent events then occurred from which Ms R could not recover. For the reasons we have explained, we do not find evidence of service failure with the decision to discharge.

1. We have carefully considered Miss R’s complaint. We were very sorry to hear of her concerns, that the decision to discharge may have affected her mother’s chance of survival.

2. We do not see any evidence of failings in the Trust’s decision to discharge Ms R on 17 March 2022. We have therefore decided to not uphold this complaint.

3. We recognise the significant emotional distress Miss R has experienced, and hope this report provides her assurance and fully explains our decision.