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A report of investigations into unsafe discharge from hospital

Issue two: Patients not being assessed or consulted properly before their discharge

Individuals who are medically fit to leave hospital may not necessarily be able to cope at home without support.

Our casework shows the damaging impact of hospitals sending elderly people home when their ongoing health and care needs have not been properly assessed and supported. This includes cases in which clinicians have failed to properly assess the individual's capacity to make decisions about whether they should go home. This is a particularly vital issue for a lot of older people with dementia and other long-term mental disorders. Clinicians should be making such assessments on and, where possible, before admission.. This failing by the hospital caused Mr L's family considerable distress.

A frail woman fell several times after being repeatedly sent home against her wishes

What happened

Mrs Z was an 80-year-old woman who lived alone and had Parkinson's disease and dementia. She had a history of depression and had attempted suicide on several occasions. After initially being admitted to hospital following a fall, she was discharged and readmitted three times over a three-month period.

The first time Mrs Z went to hospital, she asked to be sent home. Due to Mrs Z's dementia, an occupational therapist and physiotherapist both expressed uncertainty about whether she had the capacity to make this decision. Despite this, the hospital did not assess her capacity before discharging her home. Eight weeks later, Mrs Z came back to hospital, following another fall.

A nurse and a social worker were unable to agree if Mrs Z was mentally able to make a decision on whether to go home or go into residential care. Mrs Z herself was unsure and confused as to whether or not to go home. However, the hospital sent Mrs Z home without resolving the difference in opinion between the nurse and the social worker, and without arranging a full assessment of Mrs Z's capacity to make a decision.

Mrs Z fell within hours of returning home. She begged her daughter to send her back to hospital and said that she planned to end her life if she didn't. While in hospital, she told a doctor about her suicidal thoughts and asked to be placed in a care home. For a third time, Mrs Z was discharged without being properly assessed and once home, she fell again. Mrs Z said she would rather die than return to the hospital and so she was admitted to another hospital instead, where she stayed until her death three weeks later.

She begged her daughter to send her back to hospital and said that she planned to end her life if she didn't.'

What we found

We found that the hospital repeatedly failed to properly assess whether Mrs Z was mentally able to decide on her own living arrangements. Mrs Z was discharged home three times, despite her frailty and, on the third occasion, this was done against her will. We concluded that these failings caused Mrs Z and her daughter deep distress. Mrs Z had to endure the upsetting and unpleasant experience of being sent home repeatedly, only to fall or otherwise be unable to cope.

Mrs Z's daughter said she now has nightmares and can't sleep because of what happened to her mother. She said she will be haunted by the way her mother was treated for the rest of her life.

Failings in hospital discharge process meant Mr Y died in pain and discomfort

What happened

Mr Y, who suffered from Parkinson's disease and dementia, was admitted to hospital with a bladder infection. His wife, Mrs Y, originally told the hospital staff that she would take care of him after he was discharged. Later, Mrs Y changed her mind and told the hospital she felt her husband was too unwell for her to be able to care for him properly at home, and hoped that this would delay his discharge.

Four weeks after Mr Y was admitted, the hospital telephoned Mrs Y to inform her that he was medically fit and would be returning home that afternoon. Mrs Y said that she 'begged' the hospital not to discharge him, but was told that it 'needed the bed'. Mr Y was subsequently transferred to the discharge lounge at 10am, and an ambulance took him home at 4.50pm.

When Mr Y arrived home, he was unable to walk to the house unaided, and had to be supported by the ambulance crew. He collapsed into a chair, where he slept for the next 36 hours. Mrs Y was unable to rouse him, so she contacted his GP and Mr Y was taken back to hospital. At the time of Mr Y's readmission, it was noted that he had developed a large pressure sore at the base of his spine.

Eight weeks later, Mr Y was transferred to a nursing home. Sadly, he died later that month from heart failure.

What we found

Even though Mr Y was medically fit, the hospital's decision to discharge him when it did was not appropriate. There was no evidence that the hospital discussed Mrs Y's concerns about whether she would be able to care for her husband at home unsupported, and whether Mr Y needed a pressure relief mattress. There was also no evidence that the hospital talked to Mrs Y about why she had changed her mind about caring for her husband at home. Nor was there evidence that Mr Y's views or a social worker's opinion (if Mr Y lacked capacity) on his care package were taken into account, as they should have been.

Although it was reasonable for Mr Y to have been transferred to the discharge lounge to await transport home, there was no evidence that he received any nursing care in the seven hours he remained there. If he had spent those seven hours back on the ward, it is likely that he would have been repositioned regularly. Given that this did not happen, and that Mr Y subsequently spent the following 36 hours sleeping in a chair at home, it was likely that this led to the development of the pressure sore on the base of his spine. It was also likely that, if an appropriate home care plan had been put in place by the hospital, then Mr Y would have been visited by healthcare staff who could have repositioned him regularly, or raised concerns about his lack of movement sooner.

Although we concluded it was unlikely that Mr Y's pressure sore contributed to his death, we felt that it would have caused him a great deal of discomfort and distress in the final months of his life.

A woman in her 80s was discharged from hospital to an empty house, in a confused state with a catheter still inserted

What happened

Mrs F was 84 years old when she was admitted to hospital with a urine infection. She was seen by a consultant who decided she should stay in hospital for three days so that the infection could be treated and staff could monitor her. Despite this, and for reasons that are unclear, Mrs F was discharged later the same day to an empty home and in a confused state. She had been given no medication and still had a catheter inserted.

Mrs F had no family living close by. If her daughter had not asked a neighbour to call in to see her, there could have been very serious consequences for Mrs F. The neighbour contacted the ward sister at the hospital who said Mrs F should not have been discharged. An ambulance came and returned her to hospital.

Mrs F was discharged later the same day to an empty home and in a confused state.'

What we found

It was wrong to discharge Mrs F against the consultant's instructions. There was nothing in Mrs F's medical notes to explain why the consultant's instructions had been changed or who had changed them. This went against recognised standards about record keeping.

The hospital accepted that Mrs F's discharge was inappropriate, and that there was no documentation about the discharge or who arranged or authorised it. However, it failed to get to the bottom of what had happened.