First admission, April to May 2021
Supervision
28. Miss L said staff did not appropriately supervise Mr L on the ward and put him at unnecessary risk. She says he left the ward unnoticed in May 2021 and walked alone to his supported residence in his nightwear which put him at risk and caused him distress.
29. Miss L said on the day her brother was due to be discharged to a care home, he left the ward independently without staff being aware, dressed in pyjamas, dressing gown and slippers, and made his way to his former supported residence.
30. The Trust had already decided this residence could not support Mr McNulty with his ongoing care needs, and was in the process of arranging his discharge to a different care home.
31. Miss L said the residence brought Mr L back in a taxi while staff at the hospital were still unaware he had left the ward. Miss L said she received no assurance that staff took the appropriate action to ensure patient safety on the ward, especially given Mr L was a vulnerable adult.
32. The Trust acknowledged this mistake and confirmed it had submitted an incident report relating to Mr L leaving the ward unsupervised. It said it had fed back to all teams involved and discussed at the nursing team core huddle. It also acknowledged that staff did not follow necessary safety steps.
33. The NMC Code says nursing staff should work with colleagues to preserve the safety of those receiving care.
34. Mr L was especially vulnerable due to his Korsakoff’s syndrome and the Trust should have had measures in place to prioritise his safety and prevent an incident like this from occurring.
35. The records we have received do not show any evidence of the safety steps the Trust took after this incident, and we have not seen a copy of the incident report. Although this may have been an isolated incident that did not result in a significant impact, we are not assured by the evidence we have seen that the Trust has taken the appropriate action to ensure patient safety on the ward.
Discharge aftercare
36. Miss L said the Trust discharged Mr L to a care home which could not support his needs.
37. Miss L said Mr L did not get the nephrostomy bags and specialist equipment he needed which caused discomfort and skin problems leading to an ulcer and compromising his dignity.
38. The Trust acknowledged Mr L was ready for discharge and that the nursing team identified he could not manage the nephrostomies himself. It said the ward manager had taken steps to ensure Mr L was discharged to a suitable nursing home.
39. Miss L said the staff at the care home did not have experience with nephrostomies and were struggling to manage Mr L’s needs. Miss L said care home staff had also told her they were concerned about the maintenance of the drainage bags and that they were regularly leaking.
40. The Trust maintained in its response that it discharged Mr L to a suitable nursing home with the right equipment to meet his specific care need. It said the nursing home is one of the providers regularly used to support discharge of patients and is commissioned to provide services for patients with dementia related cognitive impairment and general nursing needs.
41. The Trust said the integrated discharge team had spoken to the nursing home who confirmed they had the necessary dressings and required skills to manage Mr L’s needs.
42. The records from Mr L’s first admission show staff explained to his sisters on the day before his discharge that their brother’s prostate was likely causing a blockage of urine drainage which had not improved with a catheter. They also said that nephrostomies were being inserted, and these would need to be changed every week.
43. A nephrostomy is a tube which drains urine directly from the kidney and is attached to an external drainage bag. The procedure to attach these takes place under local anaesthetic. Patients need special dressings where the nephrostomy exits the body to ensure it is kept secure and dry.
44. Miss L and her sister attended a Best Interests Meeting (BIM – a multi-disciplinary review for patients lacking mental capacity which focuses on decisions around their care and treatment) before his discharge. Nursing staff and Miss L raised concerns about Mr L’s ability to manage the nephrostomies. Miss L said Mr L could not look after the nephrostomies, and he would need a placement in a nursing home.
45. The Trust decided Mr L met the criteria for a Discharge to Assess pathway (D2A - an initiative where patients who are medically stable but require further care are discharged from the hospital to a community setting where their ongoing care needs can be managed).
46. The records show the Trust’s plan was for this to be a short-term placement followed by a review to establish where Mr L’s longer-term health and social care needs could best be met.
47. The evidence shows the Trust noted while the care home under the D2A pathway was registered to meet Mr L’s general nursing needs at the time of his discharge, he would have benefited from a long-term nursing home placement.
48. The records from the BIM state staff told Miss L that nephrostomies were a life-saving measure as he could have died from kidney failure without them. This highlights how important it was for Mr L to have the correct aftercare in place as he did not have the capacity to manage the nephrostomies himself.
49. NICE guidelines on patient experience in adult NHS services say staff should adopt an individualised approach to healthcare services that is tailored to the patient’s needs and circumstances, considering their ability to access services, personal preferences and coexisting conditions.
50. The guidelines add:
‘during discharge planning, the discharge coordinator should share assessments and updates on the person's health status, including medicines information, with both the hospital- and community-based multidisciplinary teams.’
51. Our nursing adviser said the records of the discussions held regarding discharge planning do not detail specific care needs required for aftercare and who would be responsible for the care.
52. The adviser added the specifics of aftercare in this situation would include information on how the nephrostomy tubes would be managed, for example daily checks that the nephrostomies were draining urine and observing for signs of dislodgement. The correct equipment would be the dressings required to help secure the nephrostomy tubes and spare nephrostomy drainage bags that would need to be changed.
53. We understand Miss L’s concern about the suitability of the care home to provide what she considered to be Mr L’s complex ongoing care needs. The Trust explained under the D2A pathway a clinician at the care facility reviews a patient’s care needs alongside the information the Trust provides, to ensure the care home can meet these.
54. The Trust said the care home advised they could meet Mr L’s needs and had the equipment and the skillset to manage his nephrostomies. The Trust said it took detailed steps to ensure the home was suitable.
55. The records show the Trust communicated with the care home in the days following Mr L’s discharge, as Miss L had expressed some dissatisfaction with the care home’s capacity to meet his needs.
56. The Trust contacted the care home, and it confirmed it had the necessary nephrostomy bags and had ordered a further supply. The care home also said Mr L’s skin was intact and there were no concerns about ulcers.
57. We understand Miss L said the care home did not have sufficient dressings which caused her brother to suffer discomfort and skin problems which led to him developing an ulcer. Miss L said this also caused her and her family some distress.
58. Although we find there was a lack of coordination in the Trust’s discharge of Mr L to ensure a smoother continuity of care, we have not seen evidence to say the Trust discharged him to a care home that was unsuitable for his needs and did not have the necessary equipment. The Trust took the necessary steps and were reassured by the care home that it had the skills and equipment to meet Mr McNulty’s needs.
Discharge transportation
59. Miss L says staff arranged inappropriate transportation when discharging Mr L, and he lost his belongings before arriving at the care home where staff were not expecting his arrival which caused him uncertainty and distress.
60. The Trust acknowledged Miss L’s concerns that her brother’s transfer to the care home was delayed, and it would have been better if this occurred earlier in the day. It also said patient transport can be unpredictable, and that staff escalated this multiple times to speed things up. The Trust also said Mr L was discharged with his belongings and Averill House was aware he was being discharged.
61. There is very little evidence in the records which details the arrangements for Mr L when he was discharged on 20 May. The Trust’s response explains it reviewed the records to confirm details around transportation.
62. The Trust has its own discharge policy for adult inpatients which states patients must be encouraged to use their own transport to arrive at their discharge location, unless there is a clinical or functional need to indicate otherwise.
63. The Trust acknowledged there was a clinical need for it to arrange Mr L’s transfer as he was unable to do this himself. We note he had no relatives nearby to arrange this either. We appreciate it was not ideal that this particular transfer happened late in the evening. However, this was a short journey and there is no evidence to show that Mr L needed medical care during the journey. We do not consider the Trust did anything wrong in how it arranged Mr L’s transport for this discharge.
64. In response to the complaint about Mr L’s belongings, the Trust said it discharged Mr L with his personal belongings and the care home confirmed he had these on arrival.
65. The notes from Mr L’s discharge show nursing staff documented they had packed his belongings away, although they do not specifically detail what these belongings were.
66. Miss L has not told us what belongings her brother did not have on his arrival to the care home. As the care home confirmed he had belongings with him when he arrived, we have not seen sufficient evidence to say the Trust failed to provide Mr McNulty with his belongings when it discharged him in May 2021.
Second admission, October to December 2021
Palliative care
67. Miss L complains her brother did not receive any follow-up care relating to his cancer diagnosis which delayed his treatment and caused him pain and distress. She considers he should have been seen by the palliative care team during this admission.
68. The Trust apologised Mr L was not referred to the palliative care team. It acknowledged although his physical symptoms were being managed, he may have benefited from his holistic needs being met by the palliative care team. It also said the head of nursing was working with the palliative care team to deliver a programme of education to the clinical health teams to ensure clinical staff were aware of the range of supportive measures the team could offer.
69. During the local resolution meeting with Miss L and her sister, the urology consultant involved in Mr L’s care said he has personally ensured patients who are based on the urology ward but are under his care are seen by a urology specialist prior to their discharge from hospital. The consultant said this was to ensure patients are given support with nephrostomies and to identify those who require follow-up.
70. NICE guidelines on prostate cancer diagnosis and management say organisations should:
‘offer people with metastatic prostate cancer tailored information and access to specialist urology and palliative care teams to address their specific needs. Give them the opportunity to discuss any significant changes in their disease status or symptoms as these occur. Discuss personal preferences for palliative care as early as possible with people with metastatic prostate cancer, their partners and carers. Tailor treatment/care plans accordingly and identify the preferred place of care.’
71. The Trust assessed Mr L as medically fit for discharge in October and noted he was awaiting social work input. There are several nursing entry notes which state Mr L was not in pain.
72. Our urology adviser said given Mr L’s background of Korsakoff’s and the fact he was in no pain we cannot say with certainty a palliative care referral would have made any difference at this time.
73. However, additional guidelines from the NHS national toolkit on palliative care says organisations should aim for shared decision making to ensure families and relatives are empowered to make decisions about their health. This was especially relevant for Mr L considering his lack of capacity.
74. Our adviser said the Trust had the opportunity to meet with Mr L’s family in the time between being medically fit for discharge and his discharge date to discuss expectations, prognosis and any concerns the family may have had going forward.
75. We consider the Trust should have referred Mr L for palliative care, because even if this may not have made a difference clinically, it would have been more reassuring for his family.
76. The Trust has offered its sincere apologies to Miss L and her sister that it missed an opportunity for a palliative care team referral for their brother. It said following Miss L’s complaint, the head of nursing was working with the palliative care team to deliver a programme of education to the clinical health teams to ensure clinical staff were aware of the range of supportive measures the team could offer.
77. Our Principles for Remedy say part of a remedy may be to ensure that changes are made to policies, procedures, systems, staff training or all of these, to ensure poor service is not repeated. The organisation should ensure the complainant receives an assurance that lessons have been learnt and an explanation of changes made to prevent poor service being repeated.
78. We consider the Trust has taken this issue seriously and responded positively to this aspect of Miss L’s complaint. It has apologised and has said what it intends to do to address this issue.
79. We are satisfied in principle the Trust’s actions would stop a mistake like this happening again. We note this hospital is under new management and it is likely there have been structural and policy changes since the events of Miss L’s complaint.
80. Given the seriousness with which the Trust took the complaint, and as we have not identified any clinical impact caused by the Trust’s failure to arrange palliative care, we have decided not to make any recommendations for this part of Miss L’s complaint.
81. We will continue to monitor the complaints we receive, and if we identify a comparable complaint about the Trust, we may be more likely to take further action.
Discharge medication
82. Miss L said the Trust discharged her brother in December 2021 without specialist dressings and prescriptions and did not share information on his medical condition, pain medication and care needs with his new GP.
83. The Trust apologised the information on injections and prescriptions was not on the discharge prescription. It said Mr L should have received a copy of the discharge summary which would have helped with the transfer of care to his new GP in Wales.
84. The Trust said the expectation was that when Mr L registered with a new GP, the GP would assess and identify any care needs. It apologised this was not made clear to Mr L’s family.
85. Department of Health and Social Care guidelines on hospital discharge say information should be transferred between settings clearly and in a timely way, including communicating any changes in support needs, medication and ability with relevant involved parties, such as unpaid carers, GPs and social care providers.
86. Additionally, European Association of Urology (EAU) guidelines on treatment of prostate cancer say patients with metastatic prostate cancer, once initiated on Prostap injections, should receive these either monthly or three monthly. The guidelines say these injections should continue long term to minimise the symptomatic effects of the cancer.
87. Our urology adviser said in line with these guidelines, the Trust should have included in the discharge documentation a summary of its MDT discussion regarding Mr L’s metastatic prostate cancer and the need for ongoing Prostap injections when it discharged Mr L in December 2021.
88. Our adviser added that the benefit of Prostap injections is to prevent the worsening side effects of metastatic prostate cancer, and it was important for Mr L to remain on these to relieve his symptoms as much as possible.
89. Miss L said it was only at the family’s intervention that a shared care agreement was put in place for Mr L’s Prostap injections with his new GP Practice. Miss L said this caused her and her family stress and anxiety.
90. The Trust has apologised the incorrect information on prescriptions and medication was provided and acknowledged Mr L should have received a copy of the discharge summary which would have helped with the transfer of care to his new GP.
91. We recognise Mr L was in an unfamiliar situation when he was discharged to the nursing home in south Wales, and the Trust could have done more to ensure a smoother transition to his new GP Practice, especially given his deteriorating health and ongoing care needs.
92. We acknowledge this caused Miss L and her sister stress and anxiety during what was already a worrying time, and having all the necessary information to allow for a smoother transfer of Mr L’s care may have alleviated some of their concerns. We are pleased this did not lead to any clinical impact on Mr L.
93. The Trust said at the time of its response to Miss Lin June 2023 that it was developing a revised medicine policy that it said would reinforce good practice and prevent a similar mistake happening in the future.
94. We have reviewed this policy, which states that all current medication at discharge must be noted on the prescription regardless of whether they need to be supplied or not, and the discharge summary must include details of medicines stopped, suspended or changed during admission or details of new prescriptions.
95. We are satisfied the Trust has committed to making improvements to its service to ensure it learns from mistakes. We consider the Trust’s actions are in line with our principles and are enough to put right the impact on Miss L.
Discharge transportation
96. Miss L says the Trust discharged her brother and sent him by taxi to south Wales in December 2021 without any pain relief. She says staff did not communicate the travel arrangements with her which meant she was unable to offer any help with the transfer.
97. Miss L said the travel arrangements demonstrated a total lack of compassion and considers her brother should have been discharged early the next day in view of the distance of the journey.
98. The Trust apologised Mr L had to make the journey by taxi explaining there had been service issues with the ambulances which would normally be used. It explained it booked a private ambulance for Mr L as the usual local ambulance service was unavailable at short notice due to the distance he was travelling.
99. The Trust said staff considered delaying Mr L’s transfer but said it acted in his best interests by going ahead. It also apologised Miss L was not given the opportunity to travel with her brother in the private transportation and acknowledged her presence would have made the journey more comfortable for him.
100. There is little evidence in the records which details the transfer arrangements for Mr L. The Trust response confirms the details of the transfer and that staff prescribed Mr L with 1000mg paracetamol prior to being collected. The records confirm the paracetamol prescription.
101. NICE guidelines on transition between inpatient hospital settings and community or care home settings for adults with social care needs state the discharge coordinator should consider providing people with complex needs, their families and carers, with details of who to contact about medicine and equipment problems that occur in the 24 hours after discharge.
102. Our nursing adviser said there is an expectation of a coordinated process of arranging appropriate transport for an onward journey including transfer documentation, completed discharge checklists, medications and informing family or carers and the nursing home. Our nurse adviser said these processes are not evidenced in the records provided.
103. Mr L was a vulnerable patient who lacked capacity and had nephrostomies which were surgically attached. A taxi therefore may not have been the most suitable transport for him, especially considering the length of the journey and Mr L’s frailty. The Trust has acknowledged Mr L should have been transferred by ambulance. We find this is a failing.
104. We recognise this was a challenging situation for the Trust having to arrange transport for a significant distance, given Mr L’s condition and vulnerability. This was made more difficult as Mr L’s sisters lived in south Wales and were not able to accompany him.
105. We note though that Miss L has said if the Trust had given her sufficient notice, she would have travelled to Manchester to be with her brother for the journey.
106. We consider this situation made it more important for the Trust to thoroughly plan for Mr L’s discharge and communicate with his family, and doing so would likely have alleviated some of the distress caused.
Conclusion
107. We appreciate this was a very difficult time for Miss L and her sister, as they had to advocate and provide support to their vulnerable brother while living a significant distance away from where he was receiving treatment.
108. We have found two instances of a lack of coordinated planning in the process of discharging Mr L during both of his admissions. We do not consider either of these resulted in any detrimental clinical impact on Mr L. However, they likely would have added to Miss L’s distress during what was already a distressing time.
109. We also find the Trust failed to take the necessary steps to ensure Mr L’s safety on the ward, which resulted in him leaving the hospital when he lacked capacity. We have not seen sufficient evidence to say the Trust has learned from this incident.