Discharge
20. Mrs O does not believe it was safe for the Trust to discharge Mr V on 30 November because he had undergone surgery two days earlier and had active infections.
21. The Trust said that midway through his stay, Mr V requested his discharge be prioritised as the terminal nature of his cancer meant he was keen to be at home. It confirmed the different treatments and procedures Mr V received as an inpatient and explained that he had various tests and assessments before staff were satisfied that he was fit for discharge.
22. It said Mr V did have VRE, but the infection control team found he would be safe to travel providing his wounds were suitably covered and with strict barrier contact precautions.
23. The records show Mr V reported feeling well and told staff that he was keen to go home.
24. Our nurse adviser explained a patient’s discharge is planned around set criteria, specific to that patient’s needs. The records show doctors set this criteria for Mr V.
25. Our nurse adviser confirmed that in line with the discharge planning list, the records showed improvement in Mr V’s cellulitis, and his blood markers. He reported no symptoms from his stent and was able to be stepped down to oral antibiotics.
26. The records show an Occupational Therapist reviewed Mr V on the morning of his discharge. They assessed him and observed he was able to walk independently with a stick, which was his baseline mobility status when he was first admitted. They assessed his home physiotherapy needs, which the records show resulted in a referral for short term home care.
27. Regarding MRSA, Mr V’s records only document this once, on the discharge paperwork. There are no test results for this, however, Mr V did test positive for a similar infection – VRE.
28. It seems that either we have not seen the associated records for this test, or that human error documented the wrong condition. In any event, the Joint Healthcare Infection Society (HIS) and Infection Prevention Society (IPS) guidelines for the prevention and control of methicillin-resistant Staphylococcus aureus (MRSA) in Healthcare Facilities (September 2021) notes that MRSA colonisation is not a barrier to discharging patients to another health care setting, their home or residential care.
29. Regarding VRE, also known as glycopeptide-resistant enterococci (GRE), the records show Mr V tested positive on 23 November. There is no UK guidance that says a patient should remain in hospital with this condition.
30. The HIS Guidelines for the control of GRE in Hospitals (February 2005) says that a person who tests positive in hospital should be assessed by an infection controller. It notes that the infection poses no threat to others in a residential setting, providing hygiene is followed.
31. The records reflect this assessment was done in line with the guidance. Staff noted the primary goal was to ensure the infection was contained, and to prevent it spreading to others. This assessment resulted in the plan to apply barrier cream to Mr V’s legs and dress his wounds ahead of discharge.
32. Although Mr V was readmitted in December with worsening cellulitis, our nurse adviser confirmed that all the relevant care, treatment and infection control for this condition were in place on discharge, and again there is no UK guidance that dictates an inpatient stay for this condition.
33. Our nurse adviser highlighted that most importantly, Mr V was deemed to have capacity in line with the Mental Capacity Act (2005), and there was nothing in the records to suggest that was not the case.
34. Our nurse adviser noted that because Mr V’s clinical picture at the time of discharge was stable, the criteria required for discharge was met, and that he wished to go home. There is no indication this discharge was premature, and Mr V did not go home before he was ready.
35. It would only be natural for Mr V’s family to worry, especially given his hospital stay had been very lengthy, and he had undergone surgery just a few days before discharge. When we compare what happened against what should have happened, with input from an independent nurse adviser, Mr V was fit for discharge on 30 November.
Occupational Health Assessment
36. Mrs O complains that Mr V should have undergone an occupational therapy assessment prior to discharge, because that is what the hospital’s website says he could expect. She says because he did not, it was not picked up that his bed was too high for him to access and he spent the week sleeping in a chair.
37. The Trust said occupational therapy did review Mr V. Before he went home, staff submitted referrals to community physiotherapy and the district nursing team. It said any delays from district nursing were out of the Trust’s control, because the team are employed by a different organisation.
38. The records show an occupational therapist assessed Mr V at 12.30pm on 30 November, before submitting a referral to community therapy ahead of his discharge. In this assessment, Mr V confirmed that he could remain safe between home care visits and that he had no concerns at night. This suggests Mr V was not aware he would not be able to access his bed, until he got home and the time came to use it. Given this was not obvious to Mr V, who knew of his bed’s height, we could not expect inpatient staff to have predicted this either.
39. When Mr V became aware, he was already at home with a home physiotherapy referral in place. If this problem was not picked up by the home physiotherapist, we cannot hold the Trust accountable because that service is provided by a different NHS organisation.
40. Considering Mr V did have occupational and physiotherapy assessments prior to discharge, which were completed in full, with input from Mr V, we cannot see any missed opportunities to identify this problem. With no known problem to act on, there were no further actions that staff should have taken. There is no indication that anything went wrong.
Transport
41. Mrs O complains that despite Mr V having difficulty walking due to his red, swollen, and painful legs, the Trust sent him home on 30 November in a taxi. She complains that he was sent home alone in the dark without any notice and with his limited mobility, he was expected to dress and leave very quickly.
42. The Trust confirmed Mr V agreed to his discharge before he went home but added no further comment.
43. The records show Mr V was discharged at 7pm and the journey to his home would have seen him arrive about an hour later. Mr V did have to use a stick to walk, so going home alone in winter, we can recognise Mrs O’s concern about how he managed. To arrive home prior to nightfall, staff would have had to discharge Mr V around lunchtime.
44. At noon, a doctor conducted their daily ward round. They advised staff were waiting for Mr V’s blood results to assess his level of improvement and whether he could continue on oral antibiotics at home.
45. The records show the bloods had already been taken and the results came back around 3pm. The results were good, so with the discharge criteria met, this was the earliest point he could have gone home. With late afternoon traffic to consider, it is still very likely to have been dark by the time he got home.
46. Staff told Mr V in the morning that his discharge was conditional of his test results, so he knew of the possibility early on. The records show he was informed he could go home at approximately 6pm, so we know he had about an hour before.
47. We can appreciate that Mr V had been in hospital for a long time and that this end point may have felt quite rushed. Finally going home must have felt incredibly significant for him and the wider family. However, we are not critical of hospital transport arriving promptly. We also think the notice given was sufficient to allow Mr V to get ready, and there is nothing in the notes to suggest he needed more time.
48. Our nurse adviser explained that patients are discharged via one of the Hospital Discharge and Community Support Guidance (July 2022) pathways. These range from pathway zero- no support needs, to three- the most. Mr V was discharged on pathway one, which meant he needed minimal support. His referrals for short term home support were in line with this pathway.
49. With minimal support requirements, Mr V needed hospital facilitated transport home. Our nurse adviser explained that the options open to staff would be a hospital taxi, or ambulance transport. Without the need for ongoing medical support, our nurse adviser explained that a hospital taxi was appropriate. If Mr V felt he needed ambulatory transport instead, they explained he would have been prioritised differently because there are fewer ambulances available. With patients being discharged through pathways two and three, our nurse adviser said that from experience, it is likely Mr V would have remained in hospital at least another day just waiting, when he did not need to.
50. Mrs O told us that Mr V found it difficult to navigate in the dark and we can appreciate this left him feeling vulnerable. The records do document how keen he was to go home, the guidance has no constraints as to the time of day, and we are satisfied that the transport staff arranged for him was in line with national guidance. We recognise the time he arrived home was not ideal, but it seems this took place promptly once his discharge criteria was met and through the correct means in line with his discharge pathway.
Palliative and Social Services referrals
51. Mrs O says the Trust did not submit an onward referral to the palliative care team and only made a referral for district nurses to call. Even then, she says district nurses did not attend for three days. When paramedics arrived to take some blood, she says they discovered his leg dressings saturated and had to submit a new urgent referral for district nurses to attend. By this point, Mrs O says Mr V had already deteriorated and was ultimately readmitted to hospital eight days after he was discharged.
52. She also says that Mr V’s wife has dementia and staff failed to consider that he was her main carer. She complains they submitted no social services referral, which was particularly problematic as his stay in hospital meant Mrs V did not recognise her husband when he arrived home in the night, and neither got the support they needed.
53. The Trust did not comment on social services but advised staff did submit a palliative care referral.
54. The records show the Trust submitted a palliative care referral for Mr V prior to his discharge. What happened from here is unclear because those actions were undertaken by a different NHS service. With the required referral submitted, the Trust did everything it should have.
55. The records do not include any onward referral to Social Services. On 15 and 25 November the notes reflect Mr V’s concern about his mobility in relation to his wife’s dementia. We do have to consider that the first occasion was two weeks before he was discharged, so there was plenty of scope for his mobility to improve. However, on 25 November, which was much closer to his point of discharge, a nurse documents that Mr V may need an Occupational Dependency package of care (OD POC), which our nurse adviser explained would include assessment of his social needs. It appears that nursing staff did not refer Mr V.
56. Our nurse adviser noted that Mr V’s pathway one discharge meant his personal support needs were met, but nothing wider. When we consider what happened, staff did technically work within the guidance because they appropriately assessed and addressed Mr V’s personal discharge support needs. But given the evidence of an OD POC concern, our nurse adviser explained it would have been good practice to add this in, to consider his wider needs.
57. We therefore considered whether the lack of OC POC referral led to a negative impact on Mr V, or his wife. Mrs O told us that Mr and Mrs V received no input from Social Services prior to Mr V’s admission. During Mr V’s lengthy hospital stay, Mrs V stayed with their son.
58. Mr V was only at home for eight days, so it is unlikely any Social Services input would have been underway by the time he was readmitted. However, Mrs O told us that no referral was submitted for Mr or Mrs V during this time, either by the family or by another medical professional providing his onward care.
59. We do think that staff should have provided more rounded care in considering Mr V’s caring capabilities, by submitting onward referrals to either OD POC or Social Services. This was a missed opportunity to ensure their social care needs were adequately assessed. However, it seems that neither Mr nor Mrs V required the referral, as the family had not submitted this either, when the Trust did not.
60. We do not wish to detract from the worry Mr V’s family felt around how he and Mrs V would cope going forward. Although we can recognise Mrs O’s dissatisfaction with the lack of referral, the oversight thankfully was of little clinical consequence. Given this, we have decided not to investigate further.
Complaint handling
61. Mrs O complains about long delays in the Trust answering Mr V’s and then her concerns. She says she received no explanation when staff provided timescales but then failed to maintain them and that she still has outstanding complaints that the Trust has refused to address. She says that she made this complaint for Mr V, but he never received answers to his concerns because he died before the Trust responded.
62. The Trust conducted a review of its first complaint investigation process. In its final response it apologised for the length of time that investigation had taken.
63. The NHS Complaint Standards (December 2022) accepts complaints can take time to consider. The Standards say that when investigations take longer than expected, complainants should be kept up to date.
64. Mrs O says Mr V died before he got answers to his complaint. Mr V died early January, which was one month and one day after Mrs O submitted his complaint. The records show staff told Mrs O she could expect a complaint response by mid-February. Sadly, it seems that even a swifter investigation, would not have yielded a response in time for Mr V to get the answers he wanted.
65. Mrs O received a complaint response seven months after she first complained. The Trust explained the delay was due to pressures on the urology department. We can certainly recognise her frustration as we can see through the complaint records that Mrs O had to do much of the chasing to find this out. She expresses repeatedly in her correspondence with the Trust, her understanding that investigations take time. The records show Mrs O waiting for an update in line with the timescales she was given on several occasions, before making contact herself when no update came. Staff did not act in line with the NHS Complaint Standards and keep her updated.
66. It was never going to be possible for the Trust to provide a response before Mr V died and this was apparent at the time. Considering all of the emails between the two parties, it is clear Mrs O did not receive as good a service as she should have. The Trust should have kept Mrs O better informed, and we have seen evidence that on occasion its actions did fall short of the Complaint Standards.
67. However, the lack of updates did not delay the complaint investigation itself. Internal emails support the reasons for the delays that the complaints handler describes when they did update Mrs O. Although we have seen evidence of urology actively working to progress the complaint, we can accept that this led to delays in the complaint handler updating Mrs O, which were frustrating, nevertheless.
68. Mrs O remained dissatisfied after receiving the response to her complaint in July 2024 and made a second complaint. The Trust received this by post on 6 August, and staff provided a timescale of 35-45 working days. This put the expected response date in the first week of October.
69. On the 16 October, staff told Mrs O her complaint response was being drafted. After more than two months, Mrs O received a complaint response advising the Trust had nothing further to add, though the response did detail a complete review of its first response, hence the time it took. Again, the Trust could have provided timelier updates to Mrs O.
70. Our Principles of Good Complaint Handling (February 2009) say staff should ensure that complaints are investigated thoroughly. Although the Trust answered most of Mrs O’s questions, it did not provide a response to her complaint about the Social Services referral. In line with the Principles, it should have. However, we must acknowledge that this was a lone occasion, and staff did work within the Principles when responding to everything else.
71. We want to take the opportunity to recognise the frustration Mrs O experienced because the complaints process took just over a year in total. We certainly appreciate that the answers Mr V was seeking became all the more important to Mrs O when her brother died.
72. The Principles say that NHS services should seek to put things right when they go wrong. We do think the Trust added unnecessary stress, which caused additional frustration when it was slow to provide updates, and when it missed part of her complaint, but we do not think the impact extends beyond this. The Trust did acknowledge and apologise for the length of time it took to respond. Whilst we can appreciate this may feel insufficient to Mrs O, we are satisfied it has responded in line with our Principles, and that an apology is sufficient to put right the impact of what went wrong.
73. Although the Trust did not address all of Mrs O’s concerns, we can see no value in asking Mrs O to return to the Trust for a response. We have already looked at this specific complaint as part of our investigation, so she has already received a decision from us about those concerns.
74. Although we have seen indications the Trust did not work within NHS Complaint Standards when communicating the delays to Mrs O, we have seen evidence of the Trust attempting to progress the investigation, so we do not think either response could have arrived much sooner.
75. We considered over 300 individual records, in line with national standards and guidance and with the input of an independent clinical specialist to assess whether we should take any further action on the events Mrs O complains about. In summary, we have decided not to consider Mrs O’s complaint further because although staff missed the opportunity to instigate a Social Services or OD POC referral, thankfully, this seemed not to be necessary. We could not attribute any other problems with Mr V’s standard of care to actions of the Trust, and we do not consider the frustration caused by complaint handling is sufficient to consider further.
76. We were truly sorry to learn that Mr V ultimately died following his readmission in December. We extend our deepest condolences to his family and sincerely hope this report provides a clear explanation of how we reached our decision.