4 August discharge
19. Mrs G complains the Trust discharged Mr G at 4am, when he was still unwell with a UTI. She says this resulted in his readmission later the same day, with symptoms of sepsis.
20. The Trust apologised for discharging Mr G at such an early hour. It said this was unavoidable because it does not have capacity to keep people fit for discharge until later in the day, unless there is a good reason.
21. It said his blood results looked good, and his national early warning score (NEWS), used to predict and respond to deterioration, was zero.
22. The Trust acknowledged that Mr G was confused, but showed no altered mental state associated with possible sepsis before his discharge.
23. The records show Mr G had presented at 11.16pm on 3 August with a high temperature and confusion. His heart rate was slightly elevated, and he had pain across his abdomen and bladder. He had foul smelling urine and staff diagnosed a catheter-associated UTI.
24. Two hours later, the records show Mr G’s heart rate had settled, his temperature had reduced and he was alert. Staff decided on this basis to discharge Mr G with oral antibiotics.
25. Mr G was readmitted within 12 hours of his discharge and diagnosed with urosepsis. We approached our physician adviser to assess whether staff missed any warning signs prior to discharge.
26. The records for 3 August show Mr G was screened for sepsis almost straight away.
27. NICE Suspected Sepsis in People Aged 16 or Over: Recognition, Assessment and Early Management (July 2016) prompts staff to pay particular attention to changes in a person’s usual behaviour, in addition to physiological symptoms. The records show staff performed an Abbreviated Mental Test (AMT4).
28. Our physician adviser noted that the resolution of confusion in a patient with an infection is common, but A&E staff should typically be aware that it can also be an indicator of delirium which, by its nature, fluctuates.
29. NICE Delirium Prevention, Diagnosis and Management in Hospital and Long-Term Care (January 2023) says that if indicators of delirium are identified, practitioners should conduct a 4AT assessment.
30. Our physician adviser explained a 4AT assessment in line with the guidance would likely have identified that Mr G was experiencing delirium. This is because it incorporates additional factors that AMT4 does not, such as the acute or fluctuating nature of Mr G’s confusion.
31. Our physician adviser explained that the recognition of delirium may have changed Mr G’s NEWS score and his sepsis risk score. This in turn, would likely have affected staff’s decision to discharge him, because discharge would no longer have been advisable.
32. Staff should have used the cognition and delirium assessment set out in national guidance. It seems that because they did not, Mr G did deteriorate at home, instead of in hospital.
33. It must have been upsetting when Mr G found his discharge to be so short lived. We can recognise the disruption too, with the early discharge and subsequent trip back to hospital.
34. We can see indications that this could have been avoided, had staff worked within national guidance.
35. We approached our physician adviser to assess whether Mr G being at home when he deteriorated, had caused a worse outcome than if he had remained in hospital. Reassuringly, our physician adviser could not identify any significant clinical impact caused by those few hours at home.
36. Mr G was fortunate to have Mrs G. We can see through district nursing entries, Mrs G’s prevalent worry about her husband’s returning confusion and we can recognise that this must have been stressful.
37. We do not wish to detract from the serious nature of Mr G’s condition at the time, or the worry this caused. We do think staff missed an opportunity to keep Mr G under observation, but his swift return to hospital meant there was no clinical consequence in discharging him. For this reason, we do not need to investigate this matter further.
11 August discharge
38. Mrs G complains that whilst waiting for hospital transfer, staff left Mr G in a bay with two prisoners and a drug addict. She says he felt so unsafe that he discharged himself.
39. The Trust said that Mr G had been waiting for about an hour when he informed doctors he wanted to go home. Because doctors were opposed, they asked him to pass a capacity assessment first. When he did, the Trust said staff had no powers to hold him. It said Mr G was never placed at risk from other patients.
40. The GMC Decision Making and Consent (November 2020) says doctors should give patients all the information they need, as well as the time to consider, before making an informed decision. Unless a patient lacks capacity, no one holds the legal authority to refuse treatment on their behalf, and a doctor must respect the patient’s wishes, even if the doctor disagrees.
41. The records reflect Mr G’s wish to leave and subsequent capacity assessment, which he completed in full.
42. At 6pm, Mr G discharged himself with no pre-arranged transport, advising staff he would leave in a taxi.
43. He refused medications, and the records show staff asked him to confirm that he understood he may die without them. Mr G noted he had some at home and was committed to leave against medical advice.
44. Mr G left, and the records show staff telephoned Mrs G to inform her.
45. Mr G passed a mental capacity test in line with the Mental Capacity Act (2005), which means he had the legal right to make his own decisions. Staff gave Mr G all of the information he needed and confirmed his understanding before he made an informed decision.
46. We can recognise that Mr G felt uncomfortable and concerned about his proximity to the other patients. With no escalations, confrontation or other incidents occurring as a result, we cannot agree that Mr G was forced into leaving by the circumstances, rather, his concern about what might happen. Because nothing went wrong, and because staff worked wholly within national guidance, we cannot see any indication we should consider the bay placement issue any further.
5 October discharge
47. Mrs G says that Mr G was not at his baseline mobility, and continued to vomit, but the Trust discharged him anyway. She says this resulted in his readmission by ambulance on 11 October with pneumonia and urosepsis.
48. The Trust said Mr G’s symptoms of nausea, vomiting and swelling around his penis had resolved. Staff planned to change his catheter if the UTI did not resolve and although he did deteriorate, they were satisfied he was safe for discharge as the UTI could be managed at home.
49. Regarding baseline mobility, the records show Mr G was assessed throughout his stay. He advised staff that he usually walked with a stick, had no history of falls, and had no concerns about his mobility, or managing at home.
50. The Department of Health and Social Care Hospital Discharge and Community Support Guidance (July 2022), sets out a checklist of reasons for a patient to reside in hospital.
51. Our physician adviser told us that Mr G did not meet this criteria. This is because he had a very low NEWS score, and his clinical observations had remained stable for two days. The records do not document Mr G vomiting. They note his nausea had resolved and he was eating and drinking well. It seems that perhaps his vomiting returned once at home. Our adviser highlighted that Mr G was discharged with the appropriate medication and a clear follow up plan involving specialist care.
52. Although Mr G was readmitted to hospital a week later, we are satisfied that he was fit to go home.
53. Our physician adviser explained that predicting which patients will go on to develop infection is extremely difficult. Although Mr G was more at risk due to his catheter, our adviser confirmed it would not have been possible to foresee this eventuality.
25 October discharge
54. Mrs G complains staff left Mr G in a wheelchair, in a corridor waiting for discharge for around five hours, but transport never arrived. She says when he was eventually put back into a bed at around 11pm, staff then moved him out the bed again at 4am, in favour of another patient.
55. She complains that all of this was unnecessary because Mr G was still too unwell for discharge. She says Mr G’s GP telephoned the next day because his bloods showed he was in kidney failure and sent an ambulance. Mrs G questions how staff missed this.
56. The Trust said the delays in discharge were due to pressures on the transport department and apologised. It maintained Mr G was safe to be discharged and that his subsequent complications were not evident at the time.
57. Our physician adviser reviewed Mr G’s discharge in line with the Department of Health and Social Care’s guidance on remaining in hospital. Mr G did not meet this criteria, for the same reasons as earlier in the month. Given this, our adviser was satisfied that Mr G was clinically stable for discharge.
58. Mr G’s wait for discharge sounds like it was frustrating, particularly being moved in the early hours when he was likely trying to sleep. Hospitals are dynamic places responding to ever changing demand on resources, and we can recognise the same is true for transport services. Whilst frustrating, we cannot see any indication that this could have been avoided.
59. The records show Mr G was readmitted with recurrent vomiting, rather than kidney failure. Our physician adviser explained that changes in the vomit were suggestive of a possible gastric bleed. Mr G had experienced a similar episode a few years earlier.
60. Our physician adviser explained that the multifactorial nature of Mr G’s vomiting was complex due to the interaction of various chronic conditions and given his history, it is unlikely that this could have been prevented. We cannot see any indication that Mr G was in acute kidney failure on this admission.
2 November discharge
61. Mrs G complains that her husband’s discharge was delayed by mistakes in his medication.
62. The Trust provide a basic audit trail of Mr G’s take-home prescriptions but refuted any evidence of delays. The records show that Mr G was waiting for the outcome of a barium swallow test, and a review from urology before he could go home.
63. The results came back first at 3.26pm and staff sent an initial ‘to take home’ (TTO) medications request to the pharmacy.
64. Urology reviewed Mr G at 6.48pm and asked that a doctor amend Mr G’s TTO medications, as early as possible the next morning, so Mr G could go home.
65. Mr G had a lot of medication both in and out of hospital and the audit trail shows it took the doctor from 9.54am to 11.50am to complete this review, with consistent documentation every few minutes.
66. The pharmacy then began its check two minutes later, which it completed at 2.15pm, and Mr G went home one hour later.
67. Ideally, Mr G’s medication review would have been done as soon as urology requested it at around 7pm on 1 November. However, when we consider this was a two-hour task, it is not reasonable to expect this would be done at a time where staffing would be at a minimum, given the pressures of a hospital environment.
68. Although there was a wait for Mr G’s TTO’s we cannot see that there were any unnecessary delays, and the wait was caused by amendments designed to keep Mr G safe and well. Although he did need to stay another night as a result, we are not critical of staff for being thorough.
69. We are sorry to see just how unwell Mr G had been throughout 2023. Frequent hospital admissions with short periods at home must have been worrying for Mr G and we can appreciate the emotional toll on him too.
70. Whilst we do recognise it felt like Mr G was frequently going back and forth to hospital, we have not seen sufficient evidence that anything went so wrong that it would lead us to investigate further.
Cancer Diagnosis
71. Mrs G says the Trust missed opportunities to diagnose and treat Mr G’s prostate cancer sooner. She says that despite being under active surveillance since March 2023, the Trust did not reach a diagnosis until May 2024.
72. The Trust said urology first reviewed Mr G in January 2024, and he had experienced no delays in diagnosing low grade prostate cancer. It said following a procedure on 26 March to remove excess prostate tissue - a TURP - staff discussed the results with him in May.
73. Prostate cancer is suspected when a patient has a PSA test result that exceeds the age-related thresholds set out by the NICE Assessment and Diagnosis of Prostate Cancer (February 2022). The guidance says that when a patient exceeds the threshold, secondary care should offer a biopsy to confirm or exclude prostate cancer.
74. Mr G’s age bracket put his PSA threshold below 6.5. The records show he had an elevated PSA of 6.7 as far back as 2022. The Trust did offer a biopsy, but Mr G declined. He agreed instead to annual PSA checks, indicating the next would be due in March 2023.
75. The records show Mr G had this PSA test on time and the result of 6.3, put him below the threshold for suspicion of prostate cancer set out by NICE.
76. Although the guidance does not indicate more frequent testing at this PSA level, we know staff continued to monitor this. In October 2023, his PSA was 9, which is far beyond the threshold set out by NICE for further investigations.
77. In response, the records show staff offered Mr G a routine TURP, which would help with his urinary retention and catheter problems. Staff planned to take samples from his prostate at the same time. After taking some time to think about the procedure, the records show Mr G agreed in January 2024.
78. Mr G had the TURP on 26 March. The diagnostic procedure completed on 26 April and the records show staff advised Mr G in early May. If the Trust did conduct the routine TURP as soon as Mr G agreed to the procedure, thus diagnosing Mr G’s cancer sooner, the outcome would have remained the same. Mr G had a low-grade prostate cancer that required surveillance, but no treatment.
79. When we review the records, we are satisfied they are consistent with the Trust’s account. Mr G had decided to wait between March 2022 and March 2023, and again between October 2023 and January 2024. Staff provided opportunity for further investigation at both junctures. Outside of these points, we cannot see any delays caused by the Trust in Mr G having the procedure that had any negative effects as a result.
80. Without indications that something went wrong, we cannot see a reason to investigate this further.
81. In summary, we have considered Mrs G’s complaint with input from an independent physician, and we have decided we will not take any further action.
82. Although Mr G did require a lot of hospital care, we cannot see that there were any points in which the Trust got anything wrong, outside of that initial discharge in August. Here, Mr G thankfully experienced no clinical consequence, and the rest of his readmissions, unfortunately could not have been foreseen, nor prevented.
83. We cannot imagine how upsetting a cancer diagnosis must have been for Mr and Mrs G. We were pleased to read that Mr G did not require any invasive treatment, and we sincerely hope it stays that way.