Decision Date: 14 May 2024
Mr X complained about the hospital discharge of his deceased mother, Mrs Y, by the Trust, Council and GP Practice, after Mrs Y was diagnosed with pneumonia. He complained that East Lancashire Hospitals NHS Trust should not have discharged Mrs Y from hospital and gave Mrs Y medication that she was unable to swallow. He said that the care home that Mrs Y was discharged to, under a placement by Blackburn with Darwen Council did not administer her medication properly, and did not seek medical attention for her when she deteriorated.
The appropriateness of the discharge was not criticised by the Ombudsman after taking independent clinical advice and in light of National Institute for Health and Care Excellence (NICE) Guidance. But the service agreed that communication had been lacking.
The April 2022 Discharge to Assess Guidance from the DHSC “Hospital Discharge and Community Support” was taken into account. It allows for local rather than national discharge processes that best meet the needs of the local population.
The Trust provided an appropriate apology to Mr X for poor communication and involvement and has taken reasonable steps to prevent recurrence.
The Ombudsman found fault by the Council, in that the care home did not follow up a call to the Practice. We found the care home appropriately apologised and took reasonable steps to improve services.
Regarding the complaint about the Practice, we found the Practice took appropriate action to prevent recurrence of the fault it had already identified, in not making a follow up call for a telephone consultation, and has apologised to Mr X.
What happened
Mrs Y got ill at her care home and she was treated in the Acute Medical Unit and diagnosed with pneumonia after tests. After eventual admission to a ward she was discharged back to the care home the next day. Three days later the care home contacted the GP practice which failed to get back to the manager. Two days later Mrs Y was readmitted after a 111 call and died that day.
Mr X said Mrs Y was not well enough to have left the hospital at that time. He said that the Trust failed to communicate with Mrs Y’s family about the discharge, so that her family did not get information they needed about what would happen if Mrs Y’s symptoms became worse, and whether she would then be looked after at the care home or come back to hospital. Mrs Y’s dementia meant she was unable to discuss the discharge decision herself.
Mr X also complained the antibiotics the Trust prescribed were not suitable for Mrs Y – her history of poor swallowing reflex because of her dementia diagnosis meant she could not swallow them. He said that another family member and Mrs Y’s care worker had said she was having trouble swallowing the tablets after leaving hospital. [it does not say to whom].
Mr X said Mrs Y was vomiting bile on return to the care home, and this should have been escalated. The records show three occasions when Mrs Y vomited, on 23, 24 and the night of 25 November. He said handover between care staff did not provide relevant information. The home called the practice on 24 November; both the care home and the Practice acknowledged there was no follow-up discussion of Mrs Y’s care that day. Mr X also complained the care home did not give Mrs Y her medication as it should have done.
The Practice investigated the complaint and could prove that it had booked a telephone consultation and had advised the care home it would be that afternoon. The Practice provided an extract from its records showing it made a call to the care home that afternoon, but said “there was no answer and no answerphone service”. The Practice acknowledged it had then not followed its usual process for returning calls to patients. It said its best practice protocol states it will call patients/homes on their preferred number, a minimum of two times, leaving a message where possible. It was unable to identify that a second call had been made.
The Trust asserted that it treated Mrs Y’s pneumonia in line with the NICE guideline 191, Pneumonia in adults: diagnosis and management. The Trust used a system called CURB65 alongside clinical judgement to assess how severe an illness is, and whether hospital treatment is needed or if the person can be treated at home. Home-based care is considered for scores 0-2. The Trust recorded Mrs Y’s illness as level 2, which is the threshold for considering hospital care, which she received. [Nothing is said as to the timing of these scores in relation to admission or whether the scoring was done just prior to the decision to discharge.]
Guideline 138 says intravenous antibiotics should be reviewed after 48 hours and switching to oral antibiotics should be considered; Mrs Y’s treatment was in line with this recommendation.
The discharge decision was asserted to be in line with the Department of Health Hospital Discharge and Community Support Guidance “criteria to reside” in hospital and in line with NICE guideline 191, on safe discharge from hospital (section 1.2.19):
“Do not routinely discharge people with community-acquired pneumonia if in the past 24 hours they have had 2 or more of the following findings:
- temperature higher than 37.5°C
- respiratory rate 24 breaths per minute or more
- heart rate over 100 beats per minute
- systolic blood pressure 90 mmHg or less
- oxygen saturation under 90% on room air
- abnormal mental status
- inability to eat without assistance.
- Consider delaying discharge for people with community-acquired pneumonia if their temperature is higher than 37.5°C.”
The Trust said that after being treated for pneumonia with antibiotics, Mrs Y’s observations were stable, and her blood tests showed improvement ie that she was responding to antibiotics.
The ombudsman’s report confirmed that the Trust records matched the explanation and said this:
“The clinical assessment on the morning Mrs Y was discharged, together with a physiotherapy assessment and reference to the guidance above, indicate the Trust’s decision to discharge Mrs Y back to the care home, with continuing oral treatment for pneumonia, was in line with the relevant guidance.”
[No actual details are given in the report as to how Mrs. Y’s stats were evaluated against these criteria; or her state in which she was admitted to hospital, or her state after 2 days but before she was admitted to the ward, and that must have been the point at which the 24 hour flag above would have had to have been applied. So it is not possible to work out how the ombudsman has determined that it was not inappropriate to discharge her, but it must have been the independent clinician’s interpretation of what would have been timed observations, we would suggest.]
The Trust apologised to Mr X for the lack of communication, and acknowledged this could have given him the opportunity to raise any concerns at the time.
What was found
The Trust did not act in line with the national discharge guidance (para 20). This was fault by the Trust.
The Ombudsman felt unable to guess whether it would have changed the plan for Mrs Y’s care, if the Trust had discussed discharge planning with Mr X.
Regarding the pills the Trust said it had assessed Mrs Y when she was admitted to hospital, and had not diagnosed any problems with swallowing. It said there was nothing in the nursing notes to indicate Mrs Y had any problems taking the medication.
This was borne out on a check by the Ombudsman’s investigator; meals and drinks had been adequately managed. There was insufficient evidence that the Trust should have organised a specific swallowing assessment.
Regarding the care home’s care and compliance with standards about record keeping, the investigator could see that Mrs Y vomited again during the night on 25 November and was unable to take her antibiotics that evening. There was nothing in the home’s records for 25 November to indicate the care home was still waiting for a call back, or that the care home took steps to follow up with the Practice that day.
The care home apologised and said it had shared learning with its senior teams to ensure handovers were properly documented, “to include any professional contact awaiting, this allows the team to recognise if a follow-up hasn’t been received.”
Points to note for councils, professionals, people using services and their carers, advocacy groups, members of the public
One cannot tell from the report which YEAR the events set out above took place.
In view of the steps taken since the events, by Mr X, in terms of NHS complaints etc, and what must have happened with a local authority complaint, we are guessing it was 2022, not 2023. That is relevant to which version of the Discharge to Assess Guidance was in force at the time; it’s been updated several times. But in fact it only leads out to referencing other guidance, such as NICE guidance 191, for the specific condition of community-acquired pneumonia.
Looking at the Guidance that WAS referenced in the report (https://www.nice.org.uk/guidance/cg191) we think it would have helped consider the propriety of the hospital’s conduct of the discharge to cite these two paragraphs:
Patient information
1.2.21
Explain to people with community-acquired pneumonia that after starting treatment their symptoms should steadily improve, although the rate of improvement will vary with the severity of the pneumonia, and most people can expect that by:
- 1 week: fever should have resolved.
1.2.22
Advise people with community-acquired pneumonia to consult their healthcare professional if they feel that their condition is deteriorating or not improving as expected.
The report could also have referenced whether this separate Guidance had been considered at all: Transition between inpatient hospital settings and community or care home settings for adults with social care needs.
1.1.5
Give people information about their diagnoses and treatment and a complete list of their medicines when they transfer between hospital and home (including their care home). If appropriate, also give this to their family and carers.
1.5.2
Ensure that the discharge coordinator is a central point of contact for health and social care practitioners, the person and their family during discharge planning. The discharge coordinator should be involved in all decisions about discharge planning.
If care, treatment or support is needed, the individual should be fully involved in considering what form that might take and in weighing up the risks and benefits of the options that are available. This includes, if required by the person, consultation with family members and any carers who are willing and able to provide care and support.
If you are affected by the issues in this report, please consider asking us a free One-off Question, at a level of principle, here.
The full Local Government Ombudsman report on the actions for which Blackburn with Darwen Council was found responsible, can be found here: Blackburn with Darwen Council (23 007 966)