Decision report 201200700

Summary

Miss C complained that her late mother (Mrs A), was inappropriately discharged from hospital while still suffering from a urine infection. Mrs A had diabetes and lung disease. She was admitted to hospital suffering from a number of symptoms, including confusion and fever. Mrs A was diagnosed with a urine infection and was treated with intravenous (IV) antibiotics. Mrs A was discharged after five days, but two days later was admitted to another hospital, where she died soon after admission. The cause of death was urine infection leading to kidney failure. Miss C was concerned that during Mrs A’s stay her fluid balances had not been sufficiently monitored and that she had been discharged too soon.

Our investigation, which included taking independent advice from two of our medical advisers, a doctor and a nurse, found that the care and treatment provided to Mrs A was reasonable. It was reasonable to treat Mrs A with IV antibiotics and the blood and urine tests done during her stay showed that her condition improved. The specific bacteria causing the infection was not identified until after she was discharged. This was thought to be due to the fact that Mrs A was already being treated with antibiotics before admission, which can slow down the rate at which specific bacteria can be identified in the laboratory. In the light of the improving laboratory results, it was reasonable to discharge Mrs A with oral antibiotics to continue her recovery at home. In the event, the specific bacteria proved to be a serious and potentially fatal one which was resistant to the antibiotics prescribed. However, overall we considered Mrs A’s treatment, and the discharge were reasonable.

On the matter of the fluid balance charts, both advisers commented that these charts are notoriously unreliable as so many factors influence fluid balance. However, both also noted that the charts completed in Mrs A's case were of a reasonable and acceptable standard.