Part 10 - Complaint about Peterborough and Stamford Hospitals NHS Foundation Trust (the Trust) and the Healthcare Commission (the Commission)
Jump to
Complaint about a decision to discharge from hospital an elderly vulnerable patient, who died shortly after readmission, and complaint about the Commission’s review.
Background to the complaint
Mr E, aged 88 years, went to live in a nursing home in September 2004. He suffered with severe dementia. In January 2005 he was admitted to Peterborough District Hospital with signs of internal bleeding and a chest infection, and, 17 days later he was discharged back to the nursing home. Three days later he was readmitted to the hospital where he died at the beginning of February.
The complaint to the Trust and the Commission
Mr E’s son, Mr F, complained to the Trust in February 2005. He raised concerns about the discharge decision and its planning, and their communication with the nursing home and Mr E’s GP.
The Trust replied in March 2005 that Mr E had been properly assessed and discharged safely. They apologised for the fact that the Ward Manager had failed to inform the nursing home that Mr E was no longer diabetic and for a lack of information in the discharge letter to Mr E’s GP.
Mr F remained dissatisfied and in June 2005 the Commission confirmed that it would look at his complaint. The Commission then looked at Mr F’s complaint and replied in November 2005. It referred to a breakdown in communication between the hospital and the nursing home but said it was not apparent that this was the fault of the Trust’s nursing staff. It referred to the gaps acknowledged by the Trust in their discharge letter and said that the Trust were being asked to explain what action they had taken on that point.
In December 2005 the Trust sent a further response to Mr F. They apologised for any distress caused and explained that they were trialing an electronic discharge letter. They said also that a letter used for inter-hospital transfers was being extended to transfers to nursing homes in complex cases and that the importance of providing complete and legible information in discharge letters was being emphasised in training and in staff meetings.
In December 2005 Mr F complained to the Ombudsman but as the Commission had not sought independent clinical advice during its review it was asked to look at the complaint again. In February 2006 the Commission sent its revised decision to Mr F and said that, having taken clinical advice, it took the view that the Trust’s documented actions, including the recommended follow-up actions, appeared appropriate.
What we investigated
In March 2006 Mr F complained to the Ombudsman. The investigation covered the following concerns:
- the Trust should not have discharged Mr E from hospital in January 2005;
- the Trust did not discharge Mr E with a care plan. Instead, the hospital left it to the staff at the nursing home to devise a care plan but did not provide them with sufficient information with which to write one;
- neither the nursing home nor Mr E’s GP was properly informed about his condition and treatment on discharge from hospital. Proper procedures for the discharge of vulnerable patients were not followed;
- the Trust refused to provide the nursing home with information about Mr E’s condition;
- the Commission’s handling of Mr F’s complaint was inadequate.
We examined all relevant documentation including complaint correspondence, copies of Mr E’s medical records and the Commission’s papers. We also obtained advice from a geriatrician and from a nurse with significant experience of older people’s care.
We took account of the prevailing standard which in this case was the Department of Health’s ‘Discharge from hospital: pathway, process and practice’ (2003).
What our investigation found
We did not find evidence to support the Trust’s decision that Mr E was ready to be discharged from hospital. This is not to say that, had he remained in hospital, the outcome for Mr E would have been any different. Rather, the Trust should have carried out a more thorough assessment of his needs at that time and of the ability of the nursing home to care for him. Because the acute illnesses that Mr E was suffering from had improved and his vital signs were within normal limits, it was assumed that Mr E was fit for discharge. Instead, the totality of relevant factors should have been considered. The Trust agreed that Mr E should have remained in hospital until a full assessment was made before discharge and they apologised for the fact that Mr E was discharged without more investigation into his discharge requirements.
We found that the Trust were under no obligation to discharge Mr E with a care plan.
We found that the Trust’s discharge letter was inadequate, that the use of a telephone call from the Trust to the nursing home to provide additional information was not an appropriate way to handle this complex discharge and that good practice would have involved a higher level of pre-discharge liaison with the nursing home.
We did not find any evidence to support the complaint that the Trust refused to provide the nursing home with information about Mr E.
We found that the Commission’s handling of Mr F’s complaint was inadequate as it failed to obtain independent clinical advice from an appropriately qualified person with the necessary expertise and did not give an adequate explanation for its decision.
Our investigation concluded in March 2007 and we partly upheld Mr F’s complaint against the Trust and fully upheld his complaint against the Commission.
Outcome
The Trust agreed to review their documentation on pre-discharge planning and their procedures to ensure compliance with Department of Health guidance on the proper discharge of complex elderly patients.
The Commission agreed to apologise to Mr F for the shortcomings identified in our report.
