Discharged too soon
16. When we investigate a complaint, we first look at what the organisation or clinician involved should have done. We do this by looking at what the relevant guidance says.
17. GMC: ‘Good Medical Practice’ section 15, says that clinicians ‘must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary examine the patient • promptly provide or arrange suitable advice, investigations, or treatment where necessary • refer a patent to another practitioner where this serves the patient’s needs.’
18. GMC guidance paragraph 31 says, ‘you must listen to patients, take account of their views and respond honestly to their questions’.
19. Ms R says the IHSS visited her at home and advised her to attend the ED for a possible blood transfusion because her HB levels were low at 72. HB levels measure the amount of haemoglobin in your blood. Low levels can indicate anaemia, blood loss or chronic disease.
20. Ms R says staff completed blood tests and confirmed she needed a blood transfusion. She said she then spent 36 hours in a waiting room during which time her condition deteriorated. She said her breathing got worse, she started swelling up and was delirious. She thought she was going to have a transfusion, but the ED discharged her home.
21. Mr R says her children expressed their concerns, but their views were ignored. Her daughter says she was ‘discharged against the family’s wishes as they could see worsening symptoms of confusion and swelling and tried to tell the doctors what we know from past experiences, and it fell on deaf ears’.
22. Ms R says her condition deteriorated further overnight and she was rushed back into the ED in a terrible state. She tells us she the Trust put her on a ventilator, and she needed a blood transfusion. She says her children were informed she might die. The Trust put a DNACPR in place. We can see how upsetting this situation must have been for Ms R and her children.
23. Ms R believes the Trust should not have discharged her on 6 December, and had she remained in hospital, her health would not have deteriorated to the extent it did.
24. The Trust said Ms R was triaged on arrival at the ED. Staff completed observations and assessed they were in the normal range for a person with COPD. Later, a practitioner completed further observations and documented no active bleeding and chronically low haemoglobin levels. They diagnosed chronic anaemia, worsening of COPD and possible fluid overload.
25. Chronic anaemia can be caused by a number of chronic illnesses. Fluid overload is when the body has too much water and can cause symptoms such as swelling, high blood pressure, difficulty breathing and heart issues.
26. The Trust said that a consultant reviewed Ms R and her observations. They made the likely diagnosis of non-ineffective exacerbation of COPD, not requiring oxygen, within the normal parameters and chronic anaemia. This is when a patient with COPD has increased symptoms, such as breathlessness or coughing, but does not need to be given additional oxygen.
27. The Trust recognised Ms R spent a prolonged amount of time in the ED due to the unavailability of medical beds. It says the ED discharged Ms R appropriately with advice to stop smoking, iron tablets, vitamins, inhalers and a follow up appointment with her GP. It also noted staff saw Ms R going outside to smoke during her time in the ED.
28. We can see from Ms R’s clinical records she attended the ED in November. ED staff triaged Mrs R at 1.55pm. A practitioner reviewed her at 7.38pm. The ED discharged her on the next day at 7.47pm (after 30 hours in the ED). We can see the staff referred her to the medical team but there is no record of her being seen by them.
29. Staff took Ms R’s observations on at 7.20pm on the day she attended the ED. At this time her NEW2 score was 1. Staff took her observations again the next day and her NEWS2 score was 3.
30. The NEWS2 is a scoring system that assesses a patient’s risk of deterioration based on six physiological measures, including oxygen saturation. The score ranges from 0-20 with their higher scores indicating more health concerns. Mrs R’s oxygen saturation level was at 88%. A normal oxygen saturation level for a healthy person is between 95% and 100%.
31. We asked our ED adviser whether they considered the ED discharged Ms R too soon without giving her the appropriate care and treatment.
32. Our ED adviser acknowledged the significant time Ms R spent in the ED but considers the treatment and medication Trust provided to her was appropriate whilst she was there. They explained the Trust provided Mrs R with treatment in the form of nebulisers, salbutamol and furosemide which our adviser considers was the right treatment given her observations.
33. Salbutamol helps relieve symptoms of asthma and COPD. Furosemide is a diuretic which treats the build-up of fluid in the body.
34. RCEM standards say when, ‘discharge planning includes bespoke written and verbal advice, include check of social and welfare concerns’.
35. We can see this standard was partly met with the Trust providing some advice and requesting a follow up with the GP. It noted in clinical records she lived alone. Notes do not indicate it addressed all social and welfare concerns. Ms R lives by herself, and she was still reporting experiencing symptoms.
36. Whilst our adviser said the treatment was appropriate, they note records indicate Ms R did not feel better after receiving treatment and reported increased swelling. Ms R informed the clinician she did not feel an improvement of her symptoms. Her family also raised concerns around confusion and swelling. Our adviser’s view is ED staff should have listened to Ms R’s concerns to line with Good Medical Practice. They do not think the ED should have discharged her at this point.
37. We can see the ED discharged Ms R the next day at 7.47pm. Clinical records document that her daughter found her ‘unrousable and swollen’ which prompted the second attendance at the ED. We understand how frightening this must have been for the family.
38. Ms R’s daughter’s statement reads, ‘after Ms R was discharged, she went to stay at her mother’s house because she did not feel well enough to be by herself. She went to bed but could not sleep due to breathlessness and being confused. In the morning her mother found her in bed swollen up in the face and turning blue, very confused and could not respond properly. She went straight to hospital and her oxygen saturation was 60%’.
39. When Ms R was admitted to hospital, we can see the Trust provided her with treatment in the form of nebulisers, antibiotics, diuretics and non-invasive ventilation.
40. We consider the timeline indicates Ms R deteriorated significantly over night after discharge.
41. We asked our physician adviser if they considered the outcome would have been different had Ms R remained in the hospital.
42. Our physician adviser’s view was Ms R should have been listened to in line with Good Medical Practice, and with consideration of her clinical history. They said a hospital admission would most likely have resulted in ongoing treatment for COPD, ongoing diuresis, monitoring of blood tests and vital signs. They say she may not have deteriorated due to the ongoing medical management, or she may have deteriorated anyway, although this may have been detected earlier.
43. We can see from her records, Ms R had co-morbidities and a history of needing non-invasive ventilation. Co-morbidities are the presence of one or more additional health conditions alongside the primary condition. Our physician adviser told us this indicates she is a high-risk patient in terms of potential deterioration and respiratory failure. We also can see Ms R was confused prior to discharge. Our adviser said this can be a sign of worsening respiratory failure.
44. Had she experienced the deterioration in hospital, our physician adviser says she would have then received treatment earlier. Potentially, they say, she may not have required non-invasive ventilation.
45. From the evidence we have seen, we think the Trust should have listened to the concerns of Ms R and her family and not discharged her.
Impact
46. We think the Trust should not have discharged Ms R in November 2023.
47. Ms R considers the premature discharge resulted in a deterioration in her health to the extent she felt she might die. She says this has had a long-lasting impact on her emotional and mental wellbeing and that of her children. She says she has lost faith in the NHS service she needs to access and is now frightened of attending the ED.
48. To fully assess the impact of the failing we need to look carefully at what would have happened had the Trust taken the appropriate steps by listening to Ms R and her family and not discharging her when it did.
49. Our physician adviser described it as a complex situation and on balance Ms R may have benefited from further inpatient treatment and monitoring as an inpatient. She was clinically stable but there was no improvement in her symptoms.
50. They said this is a complex case dealing with two potential scenarios, acute deterioration or stability. They say there are no routine clinical risk assessment tools or scores that Trusts use to predict which patients are high risk of deterioration and may need treatment with non-invasive ventilation.
51. We believe, had the Trust admitted Ms R to hospital rather than discharging her, staff would have further monitored and treated her. We are unable to determine the clinical impact of Ms R being discharged because our adviser considers it possible, she would have deteriorated whether at home or at hospital given her clinical history. Considering their view, we do not feel we can definitely say the discharge was the cause of her deterioration. We consider Ms R could have deteriorated even if she remained in hospital.
52. We think, Ms R should have been admitted to hospital due to clinical need. We also think it would have provided her and her family with reassurance. It would have prevented the frightening situation where Ms R deteriorated overnight at home, without clinical monitoring and care management available. We believe admission would have prevented significant distress for Ms R and her family.