3. Mrs F complains that Tameside and Glossop Integrated Care NHS Foundation Trust (the Trust) inappropriately discharged her partner, Mr O, from A&E on 26 October 2023, when he was not fit to do so.
4. Mrs F says as a result of the Trust sending her partner home prematurely, he very sadly died. She says this has caused upset and distress to her and the rest of Mr O’s family.
5. As an outcome of her complaint, Mrs F would like the Trust to acknowledge its mistakes.
6. Mr O was 73 years old. He had a history of vascular dementia, stroke, heart disease, high blood pressure and chronic obstructive pulmonary disorder (COPD).
7. Mr O had left total knee replacement surgery on 6 September 2023. He attended hospital on 7 October because of wound complications. The orthopaedic team admitted him for 10 days and prescribed antibiotics. He also developed an acute kidney injury during this admission which clinicians treated with intra-venous fluids.
8. On 25 October, Mr O attended A&E because of concerns about post-operative infection. Following assessment and tests, clinicians discharged him home in the early hours of the following morning.
9. On 27 October, Mr O went back to hospital by ambulance after having seizure at home. Clinicians later admitted him to a ward, but he never regained consciousness. Mr O very sadly died on 31 October.
13. Mrs F says the Trust inappropriately discharged her partner from A&E on 26 October when he was still very unwell. The Trust says its decision to discharge Mr O was appropriate and he did not require any further inpatient treatment.
14. COPD is the name for a group of lung conditions that cause breathing difficulties. NICE Guideline NG115 on COPD says:
1.3. An exacerbation is a sustained worsening of the patient's symptoms from their usual stable state which is beyond normal day-to-day variations and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. The change in these symptoms often necessitates a change in medication.
1.3.3 In all people presenting to hospital with an acute exacerbation:
• obtain a chest X-ray • measure arterial blood gas tensions and record the inspired oxygen concentration • record an ECG (to exclude comorbidities) • perform a full blood count and measure urea and electrolyte concentrations • measure a theophylline level on admission in people who are taking theophylline therapy • send a sputum sample for microscopy and culture if the sputum is purulent • take blood cultures if the person has pyrexia.
15. Delirium is a sudden change in mental function, often occurring over hours or days, causing confusion, altered beliefs, hallucinations, sleepiness, and agitation. NICE Clinical Guideline CG103 on delirium says:
1.3.1. At presentation, assess people at risk for recent (within hours or days) changes or fluctuations that may indicate delirium. These may be reported by the person at risk, or a carer or relative. These changes may affect:
• cognitive function: for example, worsened concentration, slow responses, confusion • perception: for example, visual or auditory hallucinations • physical function: for example, reduced mobility, reduced movement, restlessness, agitation, changes in appetite, sleep disturbance • social behaviour: for example, difficulty engaging with or following requests, withdrawal, or alterations in communication, mood and/or attitude.
If any of these changes are present, the person should have an assessment
1.6.1. If indicators of delirium are identified, a health or social care practitioner who is competent to do so should carry out an assessment using the 4AT’.
16. The 4AT is test to screen for delirium in older patients. The four items of the test are alertness, cognition (a short test of orientation), attention (recitation of the months in backwards order), and the presence of acute change.
17. Hypercalcaemia means there are high calcium levels in the blood. The NICE clinical knowledge summary on hypercalcaemia says:
Assessment of a person with unexplained hypercalcaemia includes:
• Asking about clinical features, co-morbidities, family history, and drug treatments.
• Assessing hydration status and for signs of an underlying cause.
• Reviewing the duration and pattern of hypercalcaemia.
• Arranging additional blood tests, urine tests, and chest X-ray to determine the underlying cause, depending on clinical judgement.
18. The society for endocrinology says high calcium levels can cause confusion and advises prompt treatment if symptomatic. This is mainly with intravenous fluids. Rehydration can reduce confusion and the likelihood of developing seizures.
19. The notes show Mr O attended A&E at 3:31pm on 25 October 2023, following referral from his GP because of concerns about post- operative infection. A nurse completed a triage assessment at 3:35pm and noted Mr O had started with increased confusion over the past two days and the ambulance crew had noticed an irregular pulse and an irregular heart rhythm.
20. Clinicians arranged for Mr O to have blood tests at 4pm. These showed:
• normal blood glucose (blood sugar) • normal urea and electrolytes, specifically creatinine (waste products in the blood • raised D-dimer (used as part of the investigation strategy for patients with suspected venous thrombo-embolism (blood clot)) It can also be raised due to his recent surgery and inflammation such as in Mr O’s case • low haemoglobin (protein in red blood cells). Our A&E adviser says this is common post-surgery and Mr O’s haemoglobin levels had increased since they were last checked on 16 October.
• raised serum calcium (adjusted calcium 3.07 (normal range 2.12-2.63)). This was normal on Mr O’s previous admission.
• normal c- reactive protein (measure of inflammation)
21. An ECG at 4:21pm showed a normal rhythm. Mr O also had an arterial blood gas (ABG) test at 4:23pm, which measures the amount of oxygen and carbon dioxide in a sample of blood. Mr O’s ABG showed he was hypoxic, which means there were low levels of oxygen in his body tissues.
22. Clinicians did not attempt to assess or treat this by obtaining a detailed history, arranging a chest X-ray, or prescribing steroids in line with section 1.3.3 of NICE guidance on the management of exacerbation of COPD. As set out above, Mr O also had high calcium levels. There is no evidence from the notes A&E clinicians carried out any further tests/ assessment to find out the cause and/ or treat Mr O for this, in line with the NICE clinical knowledge summary on hypercalcemia. There was also no attempt by A&E clinicians to involve the orthopaedic team, to assess if any further interventions were required for the wound infection in line with the British Orthopaedic Association guidelines.
23. Later in the evening, nurses noted Mr O had become extremely agitated, climbing out of bed, lashing out at staff and his son. Our A&E adviser tells us this was likely delirium (sudden change in mental function, often occurring over hours or days, causing confusion, altered beliefs, hallucinations, sleepiness, and agitation). Clinicians gave Mr O lorazepam at 11:30pm, which is a medication that can be used to treat anxiety and agitation. There were no attempts to assess this further using a tool such as the 4AT as set out in NICE Guideline CG103 above.
24. A doctor assessed Mr O at around 2:52am and noted he was alert and had become ‘more cooperative’ following the administration of the lorazepam. On examination of Mr O’s chest, the doctor noted he had a scattered wheeze, which is a whistling or rattling sound when breathing. His left knee was red and hot. The clinical impression was post-operative infection. The doctor decided to discharge Mr O and prescribed oral Augmentin (antibiotic) for him to take at home and advised he should follow up with his GP. Mr O left hospital at 3:14am.
25. Overall, we have seen the Trust failed to act in line with relevant guidelines when Mr O attended A&E on 25/26 October. We consider clinicians should have admitted Mr O to hospital to further investigate his hypercalcaemia, delirium, and they should have arranged orthopaedic review for his wound infection. We consider this was a failing. We have considered the impact of this was and whether it was likely admission and further investigations would have resulted in a different outcome for Mr O.
26. After being at home for around 27 hours, Mr O went back to A&E by ambulance at 8:37am on 27 October, after having a seizure at home. Mrs F says her partner was very unwell during this period. The inpatient medical team reviewed Mr O, gave him medications for seizures (levetiracetam/Keppra) and admitted him to a medical ward.
27. When the medical doctor assessed Mr O, he was unconscious because of the effects of the seizure and the medication needed to stop it. The ECG (tracing of the heart) showed a normal but fast heart rhythm. A CT brain scan showed no acute findings. The chest X-ray showed aspiration pneumonia (pneumonia due to inhalation of secretions). Sadly, Mr O continued to deteriorate, and he did not regain consciousness. He very sadly died on 31 October. Following a postmortem, the coroner concluded Mr O’s cause of death was 1 (a) cerebral infarction), 2) bronchial pneumonia, following a postmortem.
28. The histology findings on the postmortem were consistent with a recent stroke, which was the primary cause of Mr O’s death. A cerebral infarction (ischaemic stroke) occurs when the blood supply to part of the brain is blocked or reduced. A seizure is abnormal electrical activity in the brain that temporarily affects consciousness, muscle control and behaviour. A stroke can cause an increased chance of seizures. Our physician adviser explains although general unwellness can be a risk factor for seizures and it is possible high calcium levels can contribute to this, based on the postmortem findings, Mr O’s recent stroke almost certainly caused his seizure and subsequent deterioration, and his death was sadly not preventable. Mr O’s CT scan did not show the stroke. Our physician adviser says this highlights the fact that CT scans do not always provide all the answers in medicine, and Mr O’s stroke was detectable at postmortem. Even optimal treatment would have not have more than minimally improved his chance of survival.
29. Mr O’s postmortem report also confirmed there was a minor degree of microscopic bronchopneumonia and there were no indications of blood clots. Although there was evidence of mucus in the airways, our physician adviser tells us the pneumonia present at post-mortem was not extensive enough to be a primary cause of death. We therefore cannot see it is likely the failure to further investigate Mr O’s respiratory symptoms materially contributed to his sad death.
30. In summary there were several concerning factors about Mr O’s presentation on 25 October which we consider necessitated further review. We do not consider it is likely Mr O’s sad death could have been avoided had been admitted to hospital given he had a stroke which could not have been prevented. We acknowledge this experience caused Mr O and his family considerable distress. Had Mr O been admitted, this would have avoided the trauma of Mrs F witnessing her partner’s decline and seizure at home and the subsequent need for an emergency ambulance to take him back to hospital. We are very sorry to hear how this has impacted them and hope our findings have provided them with some reassurance.
1. We have decided to partly uphold this complaint. We are very sorry to hear about Mrs F’s concerns, and we recognise this has been an incredibly difficult time for her and the rest of the family.
2. We have found the Trust’s decision to discharge Mr O from A&E on 26 October was not appropriate and clinicians should have admitted him for further investigations. We have not seen it is likely this caused or materially contributed to Mr O’s sad death. We recognise these events caused additional distress to Mr O’s family and we recommend the Trust send a letter of apology and produce an action plan to show what it will do to improve services, to put this right.
13.We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.
14.Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.
What we found
15.Through investigating this complaint, we found due to the overall clinical picture when Mr O attended A&E (including delirium, hypercalcaemia and signs of COPD exacerbation), clinicians should not have discharged him home without further review/ investigations. Whilst we do not think this impacted the overall outcome, we recognise this caused additional distress.
What the organisation should do
16.Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.
The Trust should write to Mrs F to:
• Apologise for the failings we identified and the impact this had • send a copy of this letter to us by 19 January 2026.
17. Our Principles for Remedy also say organisations should look for continuous improvement and learn lessons from complaints to make sure poor service is not repeated.
We recommend the organisation:
• produces an action plan to address the failings relating to the inappropriate discharge from A&E on 26 October 2023.
• identify the reason(s) for the failing (where possible) • explain the learning taken and set out what it will do differently in the future (or does differently now) • for each action it should state who is/was responsible, timescale for completion, and how it will be/was monitored • share the action plan with us, Mrs F and by 19 March 2026.