14. Mr B has concerns his father initially presented with a skin tear, went on to deteriorate and did not come out of hospital. He questions if something was missed and if his father was discharged when it was unsafe to do so. The Trust says the appropriate treatment was provided and Mr F was fit for discharge on each occasion.
7 November 15. Mr F presented at ED after a collision with a door frame and was treated for an injury to his left hand.
16. GMC guidance is applicable here. It sets out when assessing, diagnosing or treating patients you must promptly provide suitable advice, investigations or treatment where necessary, and refer a patient to another practitioner where necessary.
17. The primary reason for the admission was due to the cut to Mr F’s hand and visible tissue loss. He experienced no loss of consciousness, dizziness, nausea or vomiting. He was appropriately triaged and assessed by a clinician based on his presenting symptoms. Mr F’s medical history was carefully considered, and his observations and examinations were carried out in line with GMC guidance.
18. The ED team then referred Mr F to the plastics for further specialist input due to the soft tissue exposure on the hand and requested an X-ray to rule out any fracture.
19. The RCEM surgical management guidance explains clinicians should inspect the wound site and check for underlying bony injury. It sets out an X-ray is a relevant investigation, and a wound may need immediate closure to allow healing. The team carried out an X-ray, ruling out a fracture, and closed Mr F’s wound with sutures.
20. Mr F had other significant comorbidities at that time, not requiring treatment in hospital but the prime reason for his attendance was the injury to his left hand. As this was the presenting complaint, it was reasonable for the ED team to focus on treating this.
21. Where Mr F needed input and advice from the plastics team this was carried out appropriately and promptly. The clinical assessment and management of his hand injury was in line with GMC and RCEM surgical management guidance.
22. We recognise Mr B has concerns his father was not safe to be discharged after this admission. The RCEM best practice guidance explains what discharge planning in ED should look like and take into consideration. Our ED adviser has considered this very carefully. We recognise the records around the discharge are quite sparse. Looking at the evidence together, our ED adviser says this suggests Mr F was safe to be discharged at this time.
23. We acknowledge Mr F ended up in hospital again shortly after this admission and understand why Mr B has concerns about this. There is a very fine balance between a patient needing treatment in hospital and aiming to get them home with treatment in place. Often when a patient remains in hospital, they can become deconditioned, and there is a risk of getting an infection in hospital.
24. Mr F had been reviewed by the hand trauma team, with a follow up plan made for him to have regular dressings which could be done in the community. His wounds had been closed, and these would not require further treatment in hospital. At that point in time, there was no clinical indication he needed further hospital treatment. His chest was stable, and the evidence suggests his deterioration happened several days later.
Although he had other comorbidities, these were not linked to the presenting complaint and did not require acute treatment. Therefore, on balance it was safe and in line with guidance to discharge him with follow up care in place in the community. We hope this provides Mr B with some reassurance around this decision making.
12 November 25. Mr F attended the Trust again with complaints of shortness of breath and chest pain. There were also concerns over the wound on his foot. The GMC guidance above is also applicable here.
26. On presenting to ED, Mr F had decreased oxygen saturations. He was also noted to have an infected foot ulcer. He was assessed, his history was considered, and he was promptly reviewed and treated with appropriate antibiotics. He was given a combination of three different strong antibiotics (vancomycin, ciprofloxacin and metronidazole) to treat a wide range of infections covering the chest and foot, with input from the microbiology team.
27. Mr F was admitted, and he was treated with oxygen, fluids, and potassium supplementation for his low potassium levels. It was arranged for Mr F to be reviewed by the plastics team, an X-ray was undertaken and there was appropriate input from the orthopaedic team.
28. Mr F was reviewed by an orthopaedic doctor on 12 November, his hand wound was examined, and this appeared to be superficial without suspicion of infection. No further orthopaedic input was required for his hand injury as a result.
29. Input was then sought for his foot wound potentially being infected on 13 November. The orthopaedic team did not think the X-ray showed any signs of osteomyelitis, an infection in the bone. The orthopaedic team advised if the medical team were clinically worried a magnetic resonance imaging (MRI) scan could be arranged. This is a medical imaging test that produces detailed pictures of inside the body. It was felt this was not urgent, as Mr F was already on a combination of strong antibiotics, as set out above.
30. Our orthopaedic adviser has carefully considered this, and if an MRI was indicated. Our orthopaedic adviser explains even if an MRI scan had been carried out, it is very unlikely this would have changed the management. This is because the treatment was antibiotics, which Mr F was already receiving. The clinical picture at that time was that Mr F was responding to the antibiotic treatment, and this management was therefore appropriate.
31. Mr F was treated for the assessed site of infection, and the appropriate specialities were involved. This management was in line with GMC guidance.
32. We understand Mr B has specific concerns about the decision to discharge his father, and we have carefully considered this. As his father needed to return to hospital so soon after discharge, we are mindful of why he may have worries about this decision. We recognise it must have been worrying for his father to have needed to return to hospital so soon after discharge.
33. The NICE transition guidance is applicable here. It sets out a framework for adults with social care needs between hospital and community care. The discharge guidance is also applicable here. Annex D of the guidance lists the criteria to reside in hospital. Generally, if a patient does not meet any of these criteria there can be an active consideration for discharge.
34. Discharge is a nuanced and finely balance process, and as set out above there is a risk of a patient getting an infection whilst in hospital or generally deteriorating. It is appropriate to aim to get patients home as soon as possible if they no longer need specific hospital treatment.
35. On admission, Mr F had raised inflammatory markers. His white cell count (WCC) was 15 and C-Reactive protein (CRP) was 141. These markers are both indicators of raised inflammation in the body. His NEWS score was four. The NEWS tool is a tool developed by the RCP, which improves the detection and response to clinical deterioration in adult patients. It is a key element of patient safety with a scoring system where a score is given to physiological measurements. A NEWS of zero to four is low risk. His score was four, which is low risk, but requires monitoring by a nurse, which was in place.
36. During the admission, Mr F’s NEWS started to drop, showing an improvement, taken alongside his infection markers improving. This suggested a response to antibiotic treatment and improving clinical picture.
37. At the time of discharge, the Trust had carried out repeat bloods which had improved. Mr F had improved inflammatory markers, with a dropped CRP and normalised potassium levels. He had been weaned off oxygen and had a NEWS of one. There was no obvious sign of osteomyelitis (a bone infection). The only treatment he was requiring at discharge was to continue the full antibiotic course. This could be completed in the community.
38. Alongside the picture of clinical improvement and stability, it was safe and appropriate to consider discharge in line with the above guidance. We understand with hindsight we now know Mr F acquired an infection whilst in hospital. His clinical observations were not suggestive of this at the time of discharge. We are mindful the clinical picture went on to develop and hope our explanation around this is helpful and provides reassurance on what was happening at the time.
18 November 39. Mr F was readmitted the following day with difficulty breathing and chest pain. He was already being treated for heart failure in line with the NICE heart failure guidance, as this was a known longstanding diagnosis he already had.
40. This guidance sets out when assessing and monitoring heart failure to take a history, perform a clinical examination and undertake standard investigations, for example electrocardiography, chest X-ray and blood tests. These investigations took place, as set out in the guidance.
41. On review, Mr F’s chest X-ray identified he had bronchiectasis and suggested he may have hospital acquired pneumonia. The HAP guidance is relevant here. Mr F was prescribed antibiotics, as is indicated in the guidance.
42. The records suggest Mr F was given one stat (one time) dose of vancomycin, a course of ciprofloxacin and a course of metronidazole. Our physician adviser has considered if this was appropriate treatment. They explain vancomycin is one of the antibiotics which is often used to treated hospital acquired pneumonia, when MRSA is suspected.
43. Based on Mr F’s clinical condition, presence of infection and concern of hospital acquired pneumonia in the context of underling bronchiectasis, our physician adviser says a 10–14-day course vancomycin should have been given opposed to a one-off stat dose on 18 November. The evidence shows he was given this again on 26 November, but we can only see he was given a one off dose when this was initially prescribed. This management was not in line with the HAP guidance, and we think this is a failing.
44. Our adviser has very carefully considered the impact of this and explains on balance, taking into account Mr F’s comorbidities and clinical frailty, it is highly unlikely this would have changed the outcome. This is because Mr F had a clinical frailty score of seven for a long time. A score of seven represents a person is ‘severely frail’ and at high risk of dying. He also had a range of comorbidities, including concurrent heart failure.
45. We have not seen any evidence to suggest Mr F would have experienced a better outcome in the circumstances but are mindful there is a possibility he would have had a reduction in his symptoms for a short period. We understand this will be upsetting for Mr B to learn that there were missed opportunities that may have provided some symptom alleviation for his father. We have not seen the Trust has acknowledged this or taken action to address it so we have asked it to take action.
46. We recognise Mr B also has concerns about the Trust’s communication with him at the end of his father’s life. He explains the Trust did not tell him or his family his father was dying before it was too late.
47. GMC guidance says you must give patients the information they want or need to know in a way they can understand, and you must be considerate to those close to the patient, and sensitive and responsive in given them information and support.
48. The records show the Trust documented starting the amber care pathway on 24 November. This is a tool used where a patient might be approaching the end of their life. This is referred to throughout the records from this point, highlighting a need to contact the family from when it was started.
49. Our physician adviser explains this is very sensitive and important decision, and family should be involved in these discussions. The family were contacted on 26 November, and there was a delay here. The Trust did not communicate with the family about Mr F’s prognosis in a timely manner in line with guidance, and we think this is a failing.
50. We have carefully considered the impact of this. We have not seen evidence to suggest the Trust communicated the severity of Mr F’s frailty with the family. This means there was a lost opportunity to have better conversations and give the family the information they need to know. Whilst this would always have inevitably been a difficult and distressing time, knowing as much information as early as possible may have alleviated some shock and anxiety. Given how frail Mr F was, there were earlier opportunities to share this with the family and help them prepare.
51. This is supported by Mr B’s account, as he has explained he was unaware of this information and was out of the country at the time. He was told on the evening of 26 November and his father died in the early hours of 27 November. He says this meant they were not able to get somebody to be with his father at the end of his life. It is understandable this caused distress, and this information should have been communicated as soon as possible.
52. We have looked to see what the Trust has done so far to recognise this. We can see the Trust has acknowledged this and agrees there was a missed opportunity. We are reassured to see the Trust has apologised for this. We think the Trust should go further to explain how any improvements will prevent this from happening in the further. We therefore ask the Trust to take action.