Hull University Teaching Hospitals NHS Trust

3. Mr D complains about Hull University Teaching Hospitals NHS Trust’s care and treatment of his mother, Mrs E, in April 2024.

4. He complains they wrongly assessed Mrs E as having capacity.

5. He complains they discharged her unsafely due to: • not doing a memory assessment • not ensuring she could manage independently with activities of living • when she was a falls risk • without a speech and language therapy (SALT) assessment • without prescribing soluble medicine • without arranging a care package • without a palliative care referral • without communicating with family during planning or the discharge itself • without correct paperwork for the fragmin injections.

6. He complains on her readmission it should have identified she was near death sooner and contacted him when it moved her to side ward and stopped her medication.

7. Mr D wants the Trust to acknowledge the failings in its care of his mother and communication with the family, and for it to take action to improve its service. Mr D also wants a financial remedy in recognition of the looking for £1,000 to reimburse the private personal care and additional financial remedy for the emotional impact on himself.

8. At the time of the events we have looked at, Mrs E was 82 years and had been diagnosed with muscle invasive TCC (transitional cell carcinoma). This is a rare form of cancer that starts in cells called transitional cells, which line the renal pelvis (a structure in the kidneys), ureters (tubes that transport urine from the kidneys to the bladder), bladder and urethra (the tube that carries urine from the bladder to the outside of the body).

9. Mrs E was admitted to hospital on 9 April 2024 for a planned cystectomy (removal of the bladder) as part of the treatment for the TCC. During the operation, the urology surgeon saw a mass on Mrs E’s small bowel and asked a colorectal surgeon to come in to examine it. The latter said it was inoperable and a biopsy (tissue sample) was taken. Mrs E was admitted to post-operative management and it was recognised her condition was not curable.

10. Mrs E was discharged home on 22 April. Mr D says that insufficient action was taken to ensure the discharge was safe. He says his mother lacked capacity to make decisions and staff did not involve the family enough, despite the fact he and his brother had lasting power of attorney. She turned down an offer of a care package. He describes the difficulty the family had managing her when she got home. They had to arrange private care. Mrs E was readmitted to hospital two days later on 24 April and sadly, died there on 26 April. We understand why he is concerned about the discharge given the difficulties the family had on her return home and the fact she had to be readmitted so soon after.

Discharge

15. The Hospital Discharge and Community Support Guidance says:

‘Hospital discharge is the final stage in an individual’s journey through hospital following the completion of their acute medical care, when they leave an acute setting and move to an environment best suited to meet any ongoing health and care needs they may have. This can range from going home with little or no additional care (simple discharge), to a short-term package of home-based or bed-based care and recovery support in the community, pending assessment of any longer-term care needs (complex discharge).

‘Whether at home or in a community setting, individuals should be discharged to the best place for them to continue recovery (if needed) in a safe, appropriate and timely way.’

16. A key aspect in ensuring a safe discharge is getting the patient as close as possible to their pre-admission functional baseline; in other words to the condition they were before their hospital admission. If this is not possible, there should be an agreement between the patient and staff as to where they will be discharged and what support (if any) the patient needs to support their discharge.

17. The Mental Capacity Act Code of Practice notes the five principles of the Act are:

• A person must be assumed to have capacity unless it is established that they lack capacity.

• A person is not to be treated as unable to make a decision unless all practicable steps to help them to do so have been taken without success.

• A person is not to be treated as unable to make a decision merely because they make an unwise decision • An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests.

• Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action

18. A person's capacity must be assessed specifically in terms of their capacity to make a particular decision at the time it needs to be made.

19. Capacity must not be determined based on age, appearance, condition or an aspect of the person's behaviour. Therefore, the fact that Mrs E had memory issues, and her sons had Power of Attorney, does not automatically mean that she lacked capacity to make decisions about her care.

20. The NICE guidance says that the starting assumption must always be that the person has the capacity, until there is proof that they lack capacity. Anyone who concludes that a person lacks capacity should be able to provide evidence. They also need to be able to demonstrate that they have taken all practicable steps to help the person make a decision for themselves.

21. If Mrs E had the capacity to be involved in discharge planning, her views would override those of her family. The Trust’s responsibility would be to ensure that Mrs E’s preference for discharge could be safely achieved.

22. There is evidence on the records that before she was discharged, Mrs E’s ability and capacity for safe discharge to her preferred place, which was her own home, was assessed.

23. Mrs E was discharged from physiotherapy on 15 April as she was mobilising and transferring well. The physiotherapist documented that Mrs E had no concerns with going home.

24. On 17 April, nursing staff noted that Mrs E’s son had raised concerns about her managing at home due to new memory problems. The nurses passed this on to the occupational therapy team. Occupational therapists (OTs) are health professionals whose role is to help people who may have difficulties carrying out day-to-day activities because of a disability, illness, trauma, ageing, and a range of long-term conditions. They play an important part in making sure patients are safe to be discharged after a hospital stay. An OT agreed to carry out an assessment both of Mrs E’s capacity and functional needs.

25. The Senior OT carried out a capacity assessment (Montreal Cognitive Assessment) on 19 April and deemed Mrs E to have capacity. She was aware of Mr D’s concern about his mother’s memory problems. In a detailed record, she noted Mrs E was ‘able to recall her memory deficits’ and was able to ‘problem solve how she would manage at home’. Therefore, we consider Mrs E’s capacity to make decisions about hr own care was assessed appropriately.

26. From a functional perspective, Mrs E was documented as independent in all transfers and mobility. A kitchen assessment was completed on the morning of 19 April (to ascertain how she could cope with preparing food and drink). This concluded she was ‘safe in the kitchen’. It included an assessment to her mobility around the kitchen,

27. The OT also did an assessment of her personal activities of daily living (PADL), focussing on her cognition and standing tolerance when washing herself at a basin.

28. The conclusion from these assessments was that she was independent and she did not need any equipment to support her discharge. Both the assessments addressed her ability to stand and mobilise in those settings.

29. The OT discussed Mrs E’s discharge needs with her son (the record does not say which son) at around 1.40pm that afternoon. Mrs E’s son was concerned about his mother’s medical situation and it was documented that the medical team were aware and would speak with him on the ward. This is documented on 22 April, with medical staff recording that Mrs E’s son was ‘concerned about taking her home and not being able to cope’. It was explained that they were still awaiting biopsy results, so it was unclear which oncology team Mrs E would be under, but she could be brought back to the ward if there were any concerns.

30. While it was recognised her condition was not curable, there is no reference during the first admission that Mrs E was so close to the end of life or in need of palliative care at that time. The discharge plan the Trust sent to Mrs E’s GP gave no indication of her requiring palliative care. The medical records show that she was continuing to receive active treatment (such as antibiotics and nutritional supplements), which is usually stopped when a person is on end-of-life care. As mentioned above, doctors were still waiting for the results of the biopsy to confirm her exact diagnosis and which oncology team would be taking responsibility for her care and treatment. In its complaint response, the Trust recognised that Mrs E had inoperable cancer and did not identify her needs to the Palliative Care team.

31. Mr D complains that his mother had difficulty swallowing and this was not addressed. He says she was unable to take medication when she was discharged.

32. We have reviewed Mrs E’s medication charts, dietitian reports and medical records from the first admission. The drug charts show that tablets were administered with no problems documented. She was seen by a dietitian after her operation, who noted that she was ‘switched to oral diet’ on 14 April. By 17 April, the dietician noted Mrs E was eating and drinking well. A dietary intake assessment the following day noted that she had eaten a variety of food types including, cereal, porridge, fruit, ice-cream, pudding and custard, three-quarters of her main meal at lunch time and a quarter of her evening meal.

33. In summary, there were no swallowing difficulties documented within this first admission and there was no indication for a SALT assessment to be done. We appreciate that when she was at home, Mrs E did have difficulty in this regard.

34. Within 48 hours of being discharged, Mrs E was readmitted due to vomiting, pain, struggling to swallow and being ‘generally unwell’. It is understandable why Mr D is so concerned why she had been discharged in the first place.

35. From the evidence we have seen, her discharge plans from a nursing and therapy perspective, were in line with national guidance in that Mrs E’s capacity and functional abilities were assessed. It was concluded that she did not require any equipment to support her discharge. It appears that Mrs Es clinical condition rapidly deteriorated after these functional assessments.

36. Regarding fragmin (an anticoagulant), Mr D described how a district nurse arrived at his mother’s home on the day of discharge and could not administer the medication as the form for it was wrong. He eventually had to take his mother back to the ward to get the correct form and there was no doctor immediately available to sort the paperwork.

37. In its complaint response, the Trust acknowledged it made a mistake and apologised. It said the form should have been checked before discharge and Mr D should not have had to bring his mother back to hospital. The Trust had taken action to ensure documentation would be completed correctly. This error understandably added to Mr D and his mother’s worry and inconvenience at what was already a very difficult time. We consider that the Trust’s response was in line with the Complaint Standards, which say organisations should be open and honest, and apologise when things have gone wrong and say how the learning will be used to improve service. As such, we do not need to take further action.

Communication at the end

38. Mr D lived some distance from his mother’s home and the hospital. Sadly, he was driving home and about an hour away from the hospital when he received a call from his brother to say their mother had died. We understand why this was so upsetting.

39. While Mr D was aware his mother was nearing the end of her life, he had not been warned that it could be a matter of hours. He thinks staff failed to tell he family that she was entering her final hours and there was a lost opportunity to have told him not to leave.

40. On the morning of 26 April, a palliative care nurse spoke to Mrs E, Mr D and his brother. At the time, they were still waiting for the result of the histology (the test of the biopsy for the operation). Mrs E expressed her desire to be discharged home and would accept a care package and the palliative nurse agreed with the family that some of her medication should be stopped with the focus now on making her comfortable.

41. That evening, a surgeon and then a doctor reviewed Mrs E and noted she was not for any invasive treatment with the aim of managing her symptoms. At 8pm, the doctor explained this to Mrs E’s son and granddaughter, who were present. There was a plan for a palliative discussion the following day. Sadly, Mrs E died soon after at 10.15pm.

42. Having carefully considered the records, we could not see any indication that the timing of Mrs E’s death could have been predicted with any more accuracy.

1. We have carefully considered Mr D’s complaint about Hull University Teaching Hospitals NHS Trust’s care of his late mother, Mrs E, in April 2024. We appreciate this was a very distressing time for Mr D and his family.

2. We have looked carefully at the relevant evidence from Mr D and the Trust. We consider the Trust took appropriate action when discharging Mrs E from hospital. As such we do not need to take further action.