Decision Report 202303760

Summary

C complained on behalf of their spouse (A). A was taken into hospital with COVID-19 and low blood sugar and was discharged after two days. That night C was concerned that A’s condition had deteriorated. A was taken to ICU and died 4 days later. The cause of death was recorded as COVID-19, ketoacidosis (where a lack of insulin causes harmful substances called ketones to build up in the blood) and renal failure. C considered that A had been discharged inappropriately in the first instance.

The board explained that A was frail. They came into hospital with chest pains from COVID-19 and were checked for pulmonary embolism. A was discharged appropriately but unfortunately deteriorated rapidly at home. Every effort was made to treat A on readmission.

We took independent advice from a consultant physician, specialising in acute medicine. We found that A had a poor state of health prior to admission, that their discharge on the first occasion was reasonable and that there was no way the discharging team could have predicted A’s subsequent deterioration. Upon A’s second admission, medical teams and intensive care teams provided a reasonable standard of management and care. Overall, we considered that the care and treatment had been reasonable and that there was no requirement for a Severe Adverse Event Review or Duty of Candour to be initiated. Therefore, we did not uphold the complaints.