Decision report 201102800

Summary
Mr C complained about the treatment that his late mother (Mrs A) received in hospital.

Mrs A was admitted with shortness of breath, and was in hospital for five days. She was discharged back to her care home but when she arrived there, staff were concerned about her condition. They contacted a GP who authorised that Mrs A be redirected to the community hospital. She was admitted to the community hospital, where she died of pneumonia some five hours after admission.

We upheld most of Mr C's complaints. We noted that before we began our investigation, the board had already accepted there were failings and communication problems, and had set out an action plan to prevent a repeat occurrence. We also established that there were communication failings between staff about the facility to which Mrs A should have been discharged. Initially the consultant had deemed that Mrs A should be discharged directly to the community hospital for palliative care but they refused as Mrs A did not require rehabilitation. This information was not passed back to the consultant, and a junior doctor decided that Mrs A could then be discharged back to the care home.

We took advice from one of our medical advisers who said that the board failed in the overall management of the care of and discharge planning for Mrs A. It appeared that arrangements for her discharge were managed by junior medical and nursing staff without any involvement of more senior staff. The inadequate arrangements that resulted from this meant that Mrs A and her family were badly let down during the final hours of her life.

Recommendations
We recommended that the board:
• take into account the adviser's comments on the action plan and provide a more detailed consideration of the failings which have been identified and demonstrate how effective the suggested measures have been; and
• apologise to Mr C for the overall manner in which Mrs A's discharge from hospital was handled.