Decision Report 202102418

Summary

C complained that the board failed to provide their adult child (A) with adequate care and treatment by discharging them from hospital when they were not medically fit to be discharged, highlighting A’s ongoing incapacity at that time.

A was admitted to hospital following an insulin overdose. Following treatment in an intensive care unit, they were transferred to a general ward. A was discharged after an in-patient stay of several days. A was readmitted to hospital by ambulance transfer the day after their discharge.

We took independent advice from an emergency medicine consultant adviser. We found that it was unreasonable for the board to have discharged A. We found that there were failings in the discharge process which had led to A being discharged with an unaddressed medical condition. Therefore, we upheld the complaint.

We also found that there had been delay in undertaking a psychiatric review. We provided feedback to the board about this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A, C, and their family for discharging A from hospital with an unaddressed medical condition leading to their readmission and for the delay in carrying out a psychiatric review. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

What we said should change to put things right in future:

• In similar circumstances, patients should be fully and appropriately assessed prior to their discharge from hospital and the assessment recorded in the patient’s clinical records.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.