East Sussex Healthcare NHS Trust

3. Mrs X complains about the care and treatment her husband, Mr X, received from East Sussex Healthcare NHS Trust prior to his death on 18 October 2024. In particular she says that the Trust, • did not put her husband on a diet plan following his admissions on 17 September and 5 October 2024 • discharged her husband home in a taxi on 27 September 2024 when he was not medically fit to be discharged and he had to be re admitted • discharged her husband home without a care plan in place to support him and the family • failed to investigate if her husband had an internal bleed after he was re-admitted on 5 October 2024 • failed to treat his infections during his second admission.

4. Mrs X says the above failings in her husband’s care affected his chance of a better outcome and he may have lived longer. Mrs X says she has been caused stress and trauma by her husband’s poor treatment.

5. Mrs X is seeking an apology for the impact of the failings and a financial remedy.

6. On 17 September 2024, the Trust admitted Mr X to hospital with a suspected upper gastrointestinal bleed. The Trust carried out an OGD (Oesophagogastroduodenoscopy) on 20 September. An OGD is a medical procedure that uses a thin, flexible tube with a camera to examine the lining of your upper digestive tract: the oesophagus, stomach, and the first part of the small intestine.

7. The medical team diagnosed Mr X with grade 2 non-bleeding varices (moderate size veins that protrude into the oesophagus). He had chronic liver disease and ascites. Ascites is the abnormal buildup of excess fluid in the space between the lining of the abdomen and the abdominal organs). It is most frequently caused by advanced liver disease or cirrhosis.

8. The Trust drained Mr X’s ascites on 26 September and discharged him home the following day. The plan was for the gastroenterology team to see him at an outpatient clinic.

9. The Trust re-admitted Mr X on 5 October as his conditioned had worsened. On 14 October, the medical team put Mr X on a last days of life personal care plan.

10. Mr X sadly died on 18 October 2024.

Mr X was not put on a dietary plan during his admissions

15. Mrs X complains that her husband was not eating and lost weight during his two admissions. She says her husband should have been put on a dietary plan. The Trust said at the local resolution meeting on 18 June 2025 that Mr X was referred to the dieticians on 10 October 2024 but there was no evidence he was seen before he passed away.

16. Our nursing adviser explained that in line with the guidance Mr X was weighed on his first admission to the Trust and a risk assessment undertaken using the MUST score, a validated tool for assessing risk of malnutrition. Malnutrition Universal Screening Tool

17. Mr X weighed 71.5 kg. He scored a MUST score of 0 meaning that at that time he was at low risk of malnutrition and required no intervention other than a weekly weight and MUST assessment.

18. Mr X had a nursing assessment undertaken on admission which deemed him independent and self-caring with his needs including eating and drinking. It was also noted that he was on a normal diet and was alert and orientated, inferring that he had capacity and could communicate his needs around nutrition.

19. It is documented throughout the nursing notes that Mr X was eating and drinking when tolerated and does not mention any concerns being raised of him not eating during his first admission. It was recognised by the Trust that Mr X should have been weighed again on 24 September, three days before his discharge. The Trust provided an apology for this which was appropriate.

20. During the second admission, a nurse weighed Mr X on 7 October and he was 71.2 kg and again had a MUST score of 0. This was two days later than it should have been done, although there is no evidence this had a negative impact on him as his weight appeared constant.

21. Our physician adviser also noted Mr X had MUST screening within the first few days of both admissions and was deemed to be of low risk, requiring no specific intervention at those times.

22. However, there is evidence from the nursing notes that during his second admission Mr X started to deteriorate and was too drowsy to eat and drink much of the time. He was given IV fluids and provided with supplements. A referral was made to the dietitian on 10 October. However, Mr X continued to deteriorate and the medical team put him on a last days of life personal care plan on 14 October. Mr X sadly died before he was seen by a dietitian, although it is unlikely that he would have received any intervention at that stage.

23. In summary, there is evidence that Mr X’s weight and nutritional needs were mainly assessed and managed in line with guidance. It is noted he should have been weighed on 24 September 2023 and on the day of his second admission. However, our nursing and physician advisers have not raised any concerns about this aspect of his care and the impact on his sad outcome.

24. Having considered the available evidence including our nursing and physician advice there are no indications of failings. Therefore, we will not be taking any further action.

Mr X was discharged home with no care plan in place

25. Mrs X complains that her husband was discharged home on 27 September 2024 without a discharge plan in place. The Trust said that following assessments by the physiotherapy integrated discharge team no care package was indicated.

26. Mr X was reviewed on the ward round by the medical team on 26 September and deemed fit for discharge home the next day. Alcohol specialist nurses also reviewed him that day and documented that he could be discharged from their point of view.

27. On the day of discharge Mr X was reviewed again by the medical team, who felt that he was safe to discharge with an outpatient follow up in the gastroenterology clinic and by his GP. The physiotherapy integrated discharge team reviewed him and assessed his suitability for a safe discharge, including a mobility and stairs assessment. No concerns were raised by the therapy team or Mr X regarding the use of stairs.

28. Mrs X says that her husband was unable to manage the stairs at home because there was only one handrail for support. The Trust said Mr X had not told them this and it would not have discharged Mr X at that time if staff had been aware. Mrs X said it is likely her husband would have said anything about there being adequate handrails as he wanted to get home.

29. It is documented that the Trust did contact Mrs X on 27 September to pick Mr X up from hospital but that she was unable to do so. Mrs X had asked if she could pick him up in the morning. By this time it was approximately 7 pm and as Mr X was not deemed as requiring ambulance transportation, he was sent home in a taxi.

30. Our nursing adviser has told us Mr X’s discharge was in general undertaken in line with Trust discharge policy and guidance. However, discussions with Mrs X regarding the discharge may have avoided the difficulties they experienced when Mr X arrived home.

31. Mrs X would have been able to discuss her concerns with the discharge team and where possible interventions arranged to alleviate these concerns. This would have been in line with the discharge policy which states,‘ 7. Involve patients and carers so that they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence’. That said, Mr X was involved in his discharge with the Trust’s discharge team in line with the discharge policy. Therefore, whilst it would have been helpful to involve Mrs X there is no indication that this shortcoming was a failing.

32. Having considered the available evidence including the nursing advice there are no indications of failings. Therefore, we will not be taking any further action.

Discharged home when not medically fit

33. Mrs X says that her husband was not medically fit to be discharged on 27 September 2026. The Trust said the absence of further episodes of bleeding, stabile blood test results and the drainage of ascites were the basis of Mr X being medically fit for discharge with follow up with the gastroenterology team.

34. Our physician adviser said that in the period leading to Mr X’s discharge there was no suggestion that he was not well enough to be discharged.

35. The medical ward round entries on the last few days do not suggest Mr X was unwell. On 26 and 27 September the records document that he ‘feels well’ and there were ‘no new concerns’. The nursing documentation for the last couple of days of admission do not highlight any concerns. The therapy entry on 27 September concludes with Mr X being discharged from physiotherapy.

36. Our physician adviser explained that patients are not required to be fully recovered and back to baseline prior to their discharge from the hospital. Frequently, a part of the recovery process is expected to take place at home.

37. The guidelines on safe hospital discharge (Hospital discharge and community support guidance - GOV.UK (www.gov.uk) outline specific criteria that should be met before a patient is sent home, and these criteria were satisfied for Mr X.

38. The guidelines acknowledge that strict adherence is not always possible, stating, "Clinical exceptions will occur but must be warranted and justified." Our physician adviser said in this case, Mr X did not meet any of the criteria that would have prevented his discharge. Additionally, there was no apparent reason to make a clinical exception to keep him in hospital. Our physician adviser said every hospital discharge inherently involves a certain level of risk that a patient might deteriorate, relapse, or struggle to cope, necessitating readmission. This risk stems from the persistent vulnerability that follows an acute illness, along with the considerable adjustments required when transitioning from hospital care to community living.

39. Having considered the available evidence and our physicians advice there are no indications of failings on the part of the Trust regarding this aspect of the complaint. Therefore, we will not be taking any further action.

Failure to investigate Internal bleed on second admission

40. Mrs X complains the medical team failed to investigate her husband for an internal bleed when he was re-admitted on 5 October 2024. She believes this was related to a bruise at the drain site for his ascites and wondered if this was due to an internal bleed.

41. The Trust said Mr X’s liver disease would have made him prone to bleeding. It suggested that the bruising may have been the result of spontaneous bleeding from his liver disease under the skin rather than outward bleeding from the drain due to a damaged blood vessel.

42. Our physician adviser said there is some evidence that Mr X may have experienced an internal bleed; specifically, in Mr X's situation, this internal bleed would have been an upper gastrointestinal haemorrhage (UGIB) resulting from oesophageal varices (dilated veins in the gullet), as happened on the previous admission. The evidence is that his haemoglobin (Hb) level had decreased. Haemoglobin is the protein in red blood cells that carries oxygen from the lings to the rest of the body. A low haemoglobin level indicates a reduced number of red blood cells, which indicates anaemia. This is a blood disorder where your body lacks enough healthy red blood cells or haemoglobin to carry adequate oxygen to your tissues.

43. However, our physician adviser said there are numerous other factors that could explain the decrease in haemoglobin, importantly, Mr X had been observed to have a significant bruise on his abdominal wall, which might explain the drop in Hb. Furthermore, for this decrease to be attributed to an UGIB, there should be additional signs, particularly the presence of blood in vomit or passed from the bowel.

44. At Mr X’s readmission on 5 October it is documented that there is no melena (black, tarry stools resulting from bleeding in the upper gastrointestinal tract) or haematemesis (vomiting blood).

45. Our physician adviser added the primary diagnostic procedure for UGIB is an endoscopy (a camera examination), which comes with significant risks, such as the potential to trigger or exacerbate bleeding from the varices, aspiration of blood or other fluids into the lungs leading to pneumonia, perforation of the oesophagus, and even death.

46. Our physician adviser told us that while there is some evidence suggesting internal bleeding in Mr X's case, there is an alternative plausible explanation for the fall in haemoglobin, and the evidence is insufficient to convincingly say that he had an internal (upper gastrointestinal) bleed that would warrant subjecting him to the significant risks associated with an endoscopy. Furthermore, our physician adviser advised that Mr X’s deterioration and death were due to multiple conditions but not an internal bleed.

47. Having considered the available evidence and our physician adviser’s advice we consider there are no indication of failings. Therefore, we will not be taking any further action.

Failure to treat infections during second admission

48. Mrs X complains that the medical team failed to treat her husband's infections during his second admission. She is particularly concerned he had sepsis and this was not identified and treated. The Trust said that Mr X had an active infection and there was a chance he had sepsis.

49. Our physician adviser said Mr X’s inflammatory markers were slightly elevated upon admission on 5 October. His blood tests showed increased levels of neutrophils (a type of white blood cell) and CRP (C-reactive protein). Both neutrophils and CRP levels rise in response to infections and various inflammatory conditions. The medical team started Mr X on antibiotics despite the absence of a confirmed infection. This was a precautionary measure in case an infection was present. These were held after review by a consultant on the afternoon of 5 October but then restarted on 6 October on the advice of the gastroenterology registrar in case there was infection in the ascites (fluid in the abdomen), a condition called spontaneous bacterial peritonitis. The antibiotics were then stopped on the consultant ward round of 8 October.

50. Mr X was then diagnosed with C.diff (Clostridioides difficile) diarrhoea. This infection most commonly affects people who are currently using or have recently used antibiotics. It is caused by a bacterium known as C. diff that produces a toxin that damages the large intestine, leading to severe diarrhoea.

51. On 13 October, a doctor noticed crackles when listening to Mr X’s chest. They requested a chest x-ray to see if there was evidence of chest infection. This was subsequently reported as not showing features of infection. Blood cultures (blood microbiology) were also obtained.

52. On 14 October, a consultant noted features suggestive of a stroke (left sided weakness). With this, Mr X’s prognosis became much worse, with a likelihood that he was sadly dying and no treatment would save him. It was decided to stop active treatment and start end of life care.

53. On 15 October, the result of blood cultures (BC) taken on 14 October were received and showed blood infection. Our physician adviser said as Mr X was dying, antibiotics were not commenced.

54. In summary, our physician adviser has told us infection and sepsis were considered throughout this admission, with very little definite suggestion of infection until the infection in the blood stream was found. They said by that time, Mr X had deteriorated to the point that it appeared he was at the end of life and antibiotics would not have saved him.

55. Our physician adviser said Mr X’s deterioration to this point was largely down to decompensated liver disease (advanced, severe liver disease such that the liver can no longer function properly, leading to life-threatening complications) and stroke. Our physician said sepsis played little, if any part, in Mr X’s deterioration.

56. Having considered the available evidence and our physician adviser’s advice we consider there are no indications of failings. Therefore, we will not be taking any further action.

Conclusion

57. We recognise that the loss of Mrs X’s husband has greatly impacted on her and her family. We have carefully considered the above issues and consider there are no indications of failings which require any further action. We hope we have been able to assure Mrs X that we have carefully considered her complaint and that we have clearly explained the reasons for our decision.

1. We have carefully considered Mrs X’s complaint about East Sussex Healthcare NHS Trust (the Trust). We have seen no indication that anything went seriously wrong.

2. We recognise that Mrs X and her family have been significantly affected by the loss of Mr X and we are sorry about that. We have set out the reasons for our decision below.