15. When we consider whether there is an indication of a failing in the care and treatment complained about, we first determine what should have happened in line with relevant policies, guidelines, standards and good clinical practice. We then use all available evidence to determine if we can say what should have happened, did happen. If it did not, we then consider if what did happen fell so far short of what should have happened that it amounts to an indication of a failing.
16. Only if we identify an indication of a failing in the care and treatment provided do we then consider the impact of this failing.
Communication
17. Mr W complains the Trust did not discuss his wife’s discharge with him, to make sure he was able to care for her.
18. The Trust said it offered Mrs W a package of care, but she declined this saying her family was able to care for her. The Trust said Mrs W had the capacity to make her own decisions, but it should have completed a formal cognitive assessment to ensure her understanding. The Trust said it did consult with Mr W, but its records are not clear as to the extent of its explanations, and it apologised if it did not clearly explain the discharge plans.
19. The Trust records contain notes from Mrs W’s first session with an OT on 2 December 2023. These notes say Mrs W told the OT she did not want a package of care at home, as she lived with her husband who would support her. Mrs W said her son would organise for her to be set up on one level downstairs. Mrs W also explained she would prefer the OT to speak to her husband when he was visiting her on the ward, rather than telephone him.
20. The notes then say Mr W arrived on the ward shortly afterwards, and the OT discussed the discharge plans with him. Mr W and his wife again declined a package of care, and Mr W said he would speak to his son about clearing space downstairs and buying a bed.
21. There are further notes from a session with an OT on 4 December, which says Mrs W again declined a package of care as her husband would support her at home. There are notes from a telephone call on 7 December which say an OT confirmed with Mr W that he was happy to help with transferring his wife from the bed to the commode. We recognise this is not in line with the contact preferences Mrs W provided earlier.
22. RCOT guidance says, ‘You give sufficient information, in an appropriate manner to enable people to give informed consent to any proposed action or intervention concerning them.’, ‘As far as possible, you enable individuals to make their own choices.’, and ‘You enable people to take the risks that they choose and to achieve their chosen goals as safely as reasonably possible.’ Our OT adviser told us the Trust’s actions were in line with this guidance.
23. The notes from the session on 2 December include a detailed section on Mrs W’s cognition, which our OT adviser told us supports the Trust’s conclusion she had the capacity to make decisions about her care. The notes from the Trust’s further interactions with Mrs W make it clear she demonstrated the ability to follow instructions, make choices about engagement, and express her needs and preferences.
24. RCOT guidance also says, ‘If the choices of an individual with mental capacity are considered unwise, they are still accepted as the individual’s choice.’
25. Our OT adviser told us the Trust’s actions were in line with this guidance.
26. RCOT guidance also says, ‘With the individual’s agreement, you actively involve their carers and/or family, keeping them informed and included in decision making as appropriate.’
27. The Trust records say the Trust discussed Mrs W’s discharge and her wishes for this with her husband on 2 and 7 December, and he agreed with this. We recognise Mr W’s recollection of the Trust’s communication with him does not align with this. We do not dispute what Mr W remembers. We have no way to say for sure what the Trust or Mr W said during these discussions, as we were not there.
28. We recognise that caring for a loved one can be difficult, especially if a person has their own health difficulties. We have seen the Trust acted correctly in involving Mr W in discussions about his wife’s discharge planning. While we do not know for sure the content of these discussions, the decision about whether Mrs W was to receive a package of care when the Trust discharged her was hers to make, and she had the capacity to make this decision. We will therefore not consider this aspect of the complaint any further.
District nurses
29. Mr W complains the Trust did not refer his wife to district nurses on discharge.
30. The Trust explained because of where Mrs W lived, its district nursing team would not have been responsible for her care. Instead, Oxleas NHS Foundation Trust (Oxleas) would have covered her area. The Trust did not address whether it referred Mrs W to Oxleas.
31. The Trust discharged Mrs W on 11 December 2023. There is no evidence of the Trust referring Mrs W to district nurses in the Trust records. Oxleas said it received a district nurse referral from the Practice, not from the Trust. The Practice records say it referred Mrs W to district nurses on 15 December.
32. Our nurse adviser told us at the point the Trust discharge Mrs W, she was clinically stable, and her knee wound was healing well. This meant Mrs W was medically optimised for discharge, and there is nothing in the Trust records which indicated she needed input from district nurses.
33. We recognise Mrs W did need the care of district nurses following her discharge. We have seen Mrs W did not require a district nurse referral at the point the Trust discharged her. We will therefore not consider this aspect of the complaint any further.
Discharge summary
34. Mr W complains the Trust did not notify the Practice it had discharged his wife.
35. The Trust did not address whether it notified the Practice of Mrs W’s discharge in its response.
36. The Trust records contain a discharge summary, and Mr W confirms he received this. However, there is no evidence the Trust sent this to the Practice in either the Trust records or the Practice records. The Practice records contain notes of a conversation on 14 December, which indicate it had not received any communication from the Trust about Mrs W’s hospital stay. The Practice notes it is going to chase this from the Trust.
37. Discharge summary guidance says, ‘The key requirements on the provider are as follows… following inpatient or daycase care or A&E attendance, to issue a Discharge Summary to the patient’s GP within 24 hours’.
38. Our OT adviser told us the Trust should have issued the Practice a formal discharge summary in line with this guidance, and this would have included details of the treatment received during admission, any changes to medication or new prescriptions, results of investigations or tests, information on follow-up appointments or future care needs, and contact details for the person responsible for ongoing support.
39. The Trust did not issue a discharge summary as it should have, in line with discharge summary guidance.
40. When we have seen something has gone wrong, we need to consider if what happened fell so far short of what should have happened that it amounts to an indication of a failing. While it would have been important for the Practice to know about Mrs W’s admission, Mr W made it aware in a call two days after the Trust discharged her. We also need to consider that Mrs W’s discharge summary did not contain any actions which the Trust was asking the Practice to take.
41. We understand Mr W would have been concerned because the Trust did not follow the correct process here. We consider that if the Trust did send the Practice Mrs W’s discharge summary as it should have, this more likely than not would not have changed the position he and his wife were in, in terms of her care and support at home. We do not consider that this mistake, in these circumstances, amounts to an indication of a failing. We will therefore not consider this aspect of the complaint any further.
Pneumonia
42. Mr W complains about the information the Trust gave him about his wife’s pneumonia. Mr W says the Trust told him it had cleared up, but she died because of it shortly afterwards.
43. The Trust said it treated Mrs W’s pneumonia appropriately with antibiotics. The Trust said while Mrs W was in ICU her condition showed improvement enough to move her back to a ward. The Trust did not specifically comment on if Mrs W’s pneumonia had cleared up by the time the Trust discharged her.
44. The Trust records say the Trust admitted Mrs W to its Intensive Care Unit (ICU) on 24 November 2023 due to hypoxia (low oxygen levels in the blood) and tachycardia (an abnormally fast heart rate), which were progressively getting worse overnight. The Trust believed Mrs W was suffering from hospital acquired pneumonia, and wanted to rule out the possibility of her having a pulmonary embolism (when a blood clot blocks a blood vessel in the lungs).
45. The Trust completed a computerised tomography (CT) scan on Mrs W the same day. The CT scan showed Mrs W had a pulmonary embolism in the lower lobe of her right lung, and changes in the lower lobe of her left lung which were consistent with pneumonia.
46. The Trust treated Mrs W with doxycycline and co-amoxiclav (antibiotics) for her suspected pneumonia, dalteparin (a blood thinner) for her pulmonary embolism, and high flow nasal oxygen for her hypoxia.
47. Mrs W took doxycycline for two days, 24 and 25 November, and co-amoxiclav for three days, from 24 to 26 November. The Trust discharged Mrs W from the ICU back to the ward on 27 November as her records say she was well enough for staff to treat her there.
48. NG250 says, ‘Consider following the section on choice, dosage and duration of antibiotics for community-acquired pneumonia for people with symptoms or signs of pneumonia starting within days 3 to 5 of hospital admission who are not at higher risk of resistance. Higher risk of resistance includes relevant comorbidity (such as severe lung disease or immunosuppression), recent use of broad-spectrum antibiotics, colonisation with multidrug-resistant bacteria, and recent contact with health and social care settings before current admission.’
49. ‘When prescribing an antibiotic(s) for community-acquired pneumonia, see the following tables for antibiotic choice, dosage and course length… table 1 for adults’.
50. Table 1 details all antibiotic courses should be five days. The Trust only provided Mrs W with antibiotics for three days.
51. When we have seen something has gone wrong, we need to consider if what happened fell so far short of what should have happened that it amounts to an indication of a failing. Our IC adviser told us it is important to consider that Mrs W’s diagnosis of pneumonia was only empirical (suspected based on clinical observations and symptoms, without a confirmed diagnosis). The radiological findings (the CT scan) suggested Mrs W had pneumonia, but urine and blood tests for pneumonia did not come back as positive. This indicates there was no clear sign of a current or recent infection, but these tests could not rule it out completely.
52. Our IC adviser told us when the Trust admitted Mrs W to ICU, all of her infection markers (c-reactive protein, white blood cells, and neutrophils) were elevated. These markers can be elevated in the case of a pulmonary embolism, pneumonia, or both or neither, so again do not indicate Mrs W definitely had pneumonia. Despite the Trust only suspecting Mrs W had pneumonia, it treated her for this alongside her pulmonary embolism.
53. The Trust records show all of Mrs W’s infection markers had come down by the point the Trust discharged her from ICU, following the joint treatment. Our IC adviser explained it is not strictly the value of these markers which is important, but the fact there was a downwards trend in them. This, alongside Mrs W being apyrexial (not having a fever), indicates she had responded to the treatment(s).
54. We do not consider that the Trust only giving Mrs W antibiotics for three days instead of five, in these circumstances, amounts to an indication of a failing.
55. The Trust discharged Mrs W approximately two weeks after it stopped her antibiotics and discharged her from the ICU. Our IC adviser told us the Trust records do not mention any deterioration in the condition of Mrs W’s chest in this time, and there is nothing to suggest she required any further treatment for it.
56. We recognise it would have been concerning for Mr W to see pneumonia mentioned on his wife’s death certificate, after the Trust told him this had cleared up during her admission. We have seen Mrs W did not require any further treatment for her chest at the point the Trust discharged her. We will therefore not consider this aspect of the complaint any further.
Mobility
57. Mr W complains about the information the Trust gave him about his wife’s mobility. Mr W says the Trust told him she could get up and mobilise, but this was not the case.
58. The Trust said following post-operative physiotherapy, Mrs W was able to get up and mobilise for up to ten metres with the use of a gutter frame, depending on her symptoms. The Trust said Mrs W could do this with either minimal or no assistance from staff. The Trust also said Mrs W demonstrated she was able to transfer in and out of bed, and independently reposition herself in bed.
59. The notes in the Trust records show Mrs W’s mobility was variable during her admission, following her operation on 22 November 2023.
60. On 23 November, the physiotherapy team noted Mrs W was able to stand to a gutter frame with the assistance of one person, perform step transfers to her commode with the gutter frame and assistance of two people, mobilise 1.5 meters with the gutter frame and assistance of two people, and required assistance of one person for moving from sitting to lying in bed.
61. Mrs W’s mobility declined upon her admission to critical care on 25 November, and improved again following her discharge back to the ward. On 1 December, Mrs W could mobilise 10 meters under supervision and with seated rests. Mrs W’s mobility fluctuated again following this, with reductions attributed to fatigue due to a period of ongoing diarrhoea.
62. Mrs W’s final physiotherapy session before the Trust discharged her was on 11 December. The Trust records say she was able to independently move from lying to sitting in bed with the use of a bed lever, and from sitting to standing with her gutter frame. Mrs W could also walk up to 5 metres with supervision and her gutter frame. The Trust had also ordered a bed lever and commode for Mrs W’s home.
63. Our physiotherapy adviser told us there is no guidance which specifies the mobility requirements for a patient to be discharged. However, it is generally accepted that if a patient is able to mobilise short distances, and their environment is set up to allow them to safely transfer and use the toilet, they are safe to be discharged. Mrs W met these criteria, given her recorded progress and the toileting adaptations put in place in her home.
64. Mr W told us when his wife got home, she could not mobilise as the Trust told him she could. The Trust records say Mrs W could do this at the point at which the Trust discharged her. We recognise Mrs W’s mobility may have deteriorated following her going home, and this would have been concerning for Mr W.
65. Discharge guidance says, ‘NHS bodies and local authorities should ensure that, where appropriate, unpaid carers and family members are involved in discharge decisions.’
66. Our physiotherapy adviser told us the Trust should have made Mr W aware his wife’s mobility was fluctuating, and it was possible she may deteriorate again. There is no evidence in the Trust records that the Trust explained this to Mr W as it should have.
67. When we have seen something has gone wrong, we need to consider if what happened fell so far short of what should have happened that it amounts to an indication of a failing. There is no way for us to know with any certainty what would have happened differently in terms of Mrs W’s care if the Trust had this conversation with her husband. It is important for us to note that Mrs W would have been aware of the fluctuations in her own mobility during her admission, and declined a package of care at home in this knowledge. As we previously determined, Mrs W had the capacity to make this decision.
68. We consider that if the Trust did have this conversation with Mr W as it should have, this more likely than not would not have changed the position he and his wife were in, in terms of her care and support at home. We do not consider that this lack of communication, in these circumstances, amounts to an indication of a failing. We will therefore not consider this aspect of the complaint any further.
69. This concludes our consideration of Mr W’s complaint. We thank Mr W for bringing us his concerns, and hope our work provides him with some reassurances.