A practice in the County Durham area

5. Mr I complains about the Trust’s decision to discharge his mother, Mrs D on 15 June 2023 with no care plan in place.

6. Mr I also complains of aspects of care and treatment the Practice provided to his mother, in December 2023. Specifically he complains the Practice: • failed to recognise she had signs of sepsis and misdiagnosed her with rhinitis.

• prescribed incorrect medication.

7. Mrs D has died. Mr I says the failings had a detrimental impact on his mother’s recovery, caused her condition to deteriorate and contributed to her death. The events leading to his mother’s death also impacted Mr I’s mental and physical health. He tells us he is experiencing mobility issues and high levels of stress.

8. Mr I is seeking service improvements as an outcome to his complaint.

9. Mrs D was 90 years old at the time of the events. She was registered blind, had hearing difficulties and a previous history of chronic kidney disease. She lived at home with her son, Mr I.

10. The Trust admitted Mrs D on 11 June 2023 with cellulitis (a bacterial skin infection). It discharged her back to her home on 15 June.

11. Following a district nurse’s observations on 21 June, Mrs D was admitted to a care home for rehabilitation treatment on 21 June. The care home discharged her back home on 13 July.

12. On 19 and 20 December 2023, the Practice attended Mrs D’s home to investigate her symptoms. It diagnosed her with rhinitis and prescribed trimethoprim (an antibiotic for bacterial infections) for a suspected urinary tract infection (UTI).

13. Mrs D sadly died on 30 December 2023.

The Trust - Discharge

17. Mr I says his mother was not fit for discharge on 15 June and the Trust did not implement an appropriate follow up care plan for her. He believes his mother required rehabilitation treatment in a care home.

18. Mr I told us he has mobility problems, requiring a walking stick as an aid. Following his mother’s discharge, Mr I told us he had to carry his mother up and down stairs. He explained a district nurse noted this and then arranged for Mrs D to go to a care home as an emergency.

19. In its response, the Trust said Mrs D was fit for discharge. It agreed there had been a miscommunication with its discharge letter and it should have discussed its decision to discharge Mrs D with her son beforehand. As a service improvement the Trust said it would feed back to staff to communicate with family effectively.

20. The Discharge guidance says from the outset people should be asked who they wish to be involved and/or informed in discussions and decisions about their discharge and planning. It says carers and providers of onward care should receive full information about the next steps of care and are given discharge information which includes safety netting arrangements.

21. It also explains during discharge planning conversations, people with new or additional needs may be offered choices of short-term health and/or social care and support in the community to aid their post-discharge recovery. The choices offered will depend on what has been put in place locally and should be suitable for a person’s short-term recovery needs and available at the time of discharge.

22. Section six of the CSP Standards emphasises the need to provide evidence of the care planned, the decisions made, the care delivered, and the information shared with the patient and their carer. Section eight explains the type of information which must be collected in the preparation of the treatment plan and discharge planning, including transfer of care.

23. Section one and two of the HCPC Standards highlights the importance of treating service users and carers with respect by working in partnership with them, and to listen to their needs and wishes in communicating effectively.

24. NICE guidelines 161 says when older people are in contact with healthcare professionals they should be routinely assessed as part of a multifactorial falls risk assessment. The multifactorial assessment includes, but is not limited, to a consideration of the following examples, assessment of balance and mobility, visual impairment and home hazards.

25. We reviewed Mrs D’s medical records for her admission and discharge at the Trust, including her GP records, with the help of our nursing adviser and our physiotherapy adviser.

26. At the time of her admission, Mrs D did not have a package of care in place. Staff noted she lived with her son who was also her main carer. She lived in a house with stairs, with her bedroom and toileting facilities on the first floor.

27. The Trust admitted Mrs D following a fall at home. The records indicate Mr I raised his concerns with the Trust that his mother was struggling with her mobility, she had increased confusion and that he also has health problems.

28. Given the concerns regarding Mrs D’s reduced mobility, the Trust requested a mobility assessment on the date of her discharge. The physiotherapy review documented Mrs D saying she manages better at home as she knows where everything is. It noted she was able to sit to stand from a chair independently. Staff noted she mobilised, with direction, from one room to another with the ‘hand hold grip of one,’ and she had ‘baseline mobility.’

29. On this basis, the Trust decided it could discharge Mrs D home as she was medically fit.

30. Our physiotherapy adviser explained an appropriate mobility assessment and decision around safe discharge should have included information from Mrs D and her son including details of the home environment, her care needs and a stairs assessment. Also the Trust should have completed a multifactorial falls risks assessment.

31. The evidence of the Trust’s review does not document all the requirements in a mobility assessment. It did not discuss the home environment or conduct a stairs assessment. Neither did it involve Mr I in its decision to discharge his mother or complete the necessary falls risk assessment.

32. The Trust’s mobility assessment was not completed in line with the Discharge guidance, CSP Standards, HCPC Standards or NICE guidelines 161 we have referred to above.

33. Both our nursing and physiotherapy advisers say it would have been in Mrs D’s best interests to be transferred directly for short term rehabilitation in a specialist setting. This is also in line with the Discharge guidance.

34. Whilst our physiotherapy adviser agrees with the service improvements the Trust says it has made in response to Mr I’s complaint, they are of the view, further improvements can be made.

35. We have found failings in the Trust’s discharge planning for Mrs D. We have considered the impact of this later in this report, as well as our recommendations.

The Practice - Sepsis

36. Mr I describes his mother as delirious around 19 December 2023. She fell in the bathroom and her carers also noted something was not right. Mr I says a GP from the Practice attended the house and diagnosed his mother with rhinitis. He says he asked the Practice to carry out tests to rule out an infection but there were delays in completing these.

37. Mr I says the Practice prescribed incorrect antibiotics, trimethoprim, which caused his mother to vomit. He believes the Practice’s delays in testing his mother’s blood and urine sample, prescribing the incorrect antibiotics and not recognising she had signs of sepsis caused her deterioration and led to her death.

38. In its response, the Practice says it did not miss signs of sepsis. It believes Mrs D’s symptoms were linked to signs of a UTI or rhinitis. It says trimethoprim is a first line antibiotic and was appropriately prescribed.

39. NICE guidelines 51 highlights the typical observations which can be indicative of suspected sepsis. This includes an increased heart rate, high temperature, blood pressure and changes in colour of skin, lips and tongue. Also if a patient is displaying an altered mental state, have mottled skin, and are unable to pass urine.

40. The GMC Guidance describes what is expected of all doctors. At section 15, it highlights when assessing or diagnosing patient’s doctors must adequately assess the patient’s condition, consider their history and promptly arrange suitable investigations or treatment where necessary. At section 16 it explains drugs should be prescribed only when a doctor has adequate knowledge of the patient’s health and it should provide effective treatment, based on the available evidence.

41. NICE guidelines 109 provides guidance on the first choices of antibiotic treatment for women with a suspected UTI. It also explains the suitability of the antibiotic treatment during the interim period when a urine sample has been sent for culture and susceptibility testing. It states the two choices of antibiotic treatment are nitrofurantoin and trimethoprim.

42. We reviewed Mrs D’s GP records with the help of our GP adviser.

43. The Practice’s home visit dated 19 December documented Mrs D had a chesty cough which had resolved. It also entered ‘?rhinitis,’ on the records. The GP examined Mrs D’s chest, and noted it was clear from signs of infection. The Practice arranged a second home visit the following day because Mrs D had another fall.

44. During this home visit, one of Mrs D’s carers raised concerns of a UTI. The Practice agreed a plan with Mrs D to hand in a urine sample to the Practice for testing. We note the Practice did not document rhinitis as a potential diagnosis again during this home visit. The Practice prescribed trimethoprim on 21 December.

45. Our GP adviser explained there were no obvious signs of sepsis during the home visit on 19 December. They explain rhinitis was entered on the records because it can cause a runny, blocked nose, sneezing and coughing.

46. Our GP adviser notes on 20 December, Mrs D was seen by the same doctor as the day before. She was sitting up on the sofa when the GP arrived. They noted her chest was clear again and examined her ears. Mrs D did not seem to have evidence of a new altered mental state, and her blood pressure was normal. There was no mention of any skin mottling.

47. Our GP adviser explained whilst best practice indicates a patient’s observations such as their pulse, respiratory rate and temperature should be recorded, this is not detailed on the records. However, despite this our GP adviser is of the view Mrs D’s symptoms were not indicative of sepsis at this time, particularly given her blood pressure was at normal levels.

48. Whilst the additional information of Mrs D’s observations would have been helpful in painting a clearer picture of her clinical presentation on both home visits. From the evidence we have seen, it is clear her symptoms were not indicative of sepsis at that time.

49. We have found the Practice’s assessments of Mrs D during the home visits were in line with NICE guidelines 51 and the GMC Guidance. It carried out a number of the relevant observations for sepsis from the NICE guidelines, and these were suitable investigations to assess her condition.

50. We next asked our GP adviser if the Practice should have prescribed trimethoprim.

51. Our GP adviser explained Mrs D had a history of recent Clostridioides difficile (C. diff) infection. This can be a life-threatening condition where the patient gets diarrhoea often following antibiotics therapy. Therefore a doctor would be cautious about prescribing antibiotics when only necessary.

52. In this case the Practice appropriately requested a urine sample to further check for urine infection. As Mr I was concerned about leaving his mother without antibiotics over the forthcoming weekend, the Practice appropriately prescribed trimethoprim, which is one of the first-line antibiotics for a UTI.

53. Our GP adviser further explained a second antibiotic called nitrofurantoin is usually the first-line treatment for a UTI, but it must be used in caution with someone with kidney disease. Therefore the Practice made the appropriate decision to prescribe Mrs D trimethoprim until her urine sample results came back.

54. The Practice prescribed the antibiotics in line with NICE Guidelines 109 and we have found no failing here. We hope this provides Mr I with reassurances the Practice’s treatment plan for his mother during this time, was in line with relevant guidelines.

Impact

55. We consider the Trust should have completed a full mobility assessment and stairs assessment. It should have discussed the discharge planning with Mrs D’s son to understand his needs and wishes.

56. On the balance of probabilities, had the Trust taken this action, it would have realised it was not safe to discharge Mrs D back home and she required further rehabilitation treatment in a care home.

57. The Trust’s decision to discharge Mrs D back to her home placed Mr I in a period of difficulty. Mr I has told us he has his own health and mobility issues, and he uses a walking stick as an aid. Following his mother’s discharge, Mr I told us he had to carry his mother on his back to take her down the stairs whilst also holding his walking stick to aid his own mobility.

58. This placed additional burden, distress and anxiety on Mr I, which continued for seven days, until a district nurse recognised his mother urgently required rehabilitation treatment in a care home.

59. We are very sorry to learn about the upset and distress these events caused Mr I. It is clear from our communication with him that this was a very difficult time for him both physically and mentally.

60. Mrs D was discharged from the Trust on 15 June. She was admitted to a care home for rehabilitation treatment for three weeks on 21 June and discharged on 13 July. As Mrs D sadly died on 30 December, over six months after her discharge from the Trust, we have not found the failings caused or contributed to her death. This means we cannot link the failings to all the injustice Mr I claims.

61. However, if the failings had not happened, we consider this would have made a difference to Mr I, as it would have given him the reassurance the Trust had completed a robust discharge assessment for his mother, with his involvement. It also would not have placed Mr I in a difficult situation where he had to care for his mother without appropriate support, which was particularly unsafe, given his own mobility issues. Therefore, we consider the failings caused Mr I avoidable distress.

62. We set out our current thinking on recommendations below.

1. Mr I complains about the care and treatment County Durham and Darlington NHS Foundation Trust (the Trust) and a GP Practice in the Durham area (the Practice), provided to his mother, Mrs D in June and December 2023. We were very sorry to learn about Mr I’s concerns and for the loss of his mother. We recognise this has been a very upsetting time for Mr I.

2. We have not found any failings in the Practice missing signs of sepsis, diagnosing Mrs D with rhinitis (an inflammation of the inner lining of the nose leading to congestion) or prescribing her incorrect medication.

3. We have found the Trust’s physiotherapy assessment and its decision to discharge Mrs D was not in line with national guidelines. Whilst we have not linked these failings to Mrs D’s death, this caused Mr I distress and further burden on him.

4. We therefore partly uphold this complaint. We recommend the Trust should issue an action plan explaining what steps it has taken, or will take, to avoid repetition of the failings we have found.