Sheffield Teaching Hospitals NHS Foundation Trust

3. Mrs K complains about the care and treatment provided by Sheffield Teaching Hospitals NHS Foundation Trust (the Trust) to her brother, Mr L, during his admissions to hospital between October and December 2023. Mrs K says the Trust inappropriately discharged her brother on 4 separate occasions:

• 4 November 2023 • 21 November 2023 • 1 December 2023 • 14 December 2023

4. She says her brother should not have been discharged on any of these occasions as he was not in a suitable condition to be allowed home. She says on each occasion the Trust failed to take into account her brother’s individual circumstances and needs. She says the Trust failed to put in place an adequate plan of care or ensure the family were involved in his discharge arrangements. She says as a result her brother had to return to hospital very soon after he was discharged on each occasion for further treatment.

5. Mrs K says the Trust also failed carry out the appropriate investigations to diagnose the pulmonary embolism which led to her brother’s death. She says if the Trust had identified this and provided appropriate treatment his condition may not have deteriorated and he may not have died.

6. Mrs K would like the Trust to acknowledge the failings in the care it provided to her brother and apologise for the impact they had. She wants the Trust to improve its service for the benefit of other patients and make a financial payment in line with the Ombudsman’s guidance on financial remedy.

7. Mr L was a vulnerable adult with learning difficulties and a medical history of type 2 diabetes and heart failure. He had a home care plan in place where he was supported by a carer as well as his family. He was taken to A&E at the Trust on 30 October 2023 due to a two-week history of behavioural change, knee pain, recent falls and reducing mobility and weight loss. He was admitted to hospital for further tests and treatment.

8. Blood tests showed evidence of raised infection markers and a CT scan confirmed he was suffering with a chest infection which the Trust treated with antibiotics. The Trust discharged Mr L several times but on each occasion he returned to hospital for further treatment. Mr L sadly died on 15 December 2023.

12. The NEWS guidance says:

‘Adult patients in acute hospitals should have physiological observations recorded at initial assessment or admission. Physiological observations should then be monitored at least every 12 hours. NEWS is recommended as the system endorsed by NHS England.’

13. NEWS is used to assist early detection of deterioration in a patient’s condition and the risk of future deterioration. It does this by measuring the 6 main physiological parameters of pulse rate, blood pressure, respiratory rate, oxygen levels, temperature and level of consciousness and allocating a score of 0, 1, 2 or 3 to each parameter. The higher the score, the further the parameter is from the normal range. The scores are then considered to establish the patient’s risk of clinical deterioration as follows:

• Low risk (aggregate score 1 to 4) • Low to medium risk (score of 3 in any single parameter) • Medium risk (aggregate score 5 to 6) • High risk (aggregate score of 7 or over)

14. The discharge guidance says:

‘Every person on every general ward should be reviewed on a twice daily ward round to determine the following. If the answer to each question is ‘no’, active consideration for discharge to a less acute setting must be made:

• requiring ITU or HDU care?

• requiring oxygen therapy/NIV?

• requiring intravenous fluids?

• NEWS greater than 3?

• diminished level of consciousness where recovery realistic?

• acute functional impairment in excess of home or community care provision?

• last hours of life?

• requiring intravenous medication?

• undergone lower limb surgery within 48 hours?

• undergone thorax-abdominal/pelvic surgery with 72 hours?

• within 24 hours of an invasive procedure?’

15. The GAIN guidance says:

‘Individuals with a learning disability and where appropriate, their family/carers, will have a thorough and coordinated approach to discharge planning that meets their specific needs. Discharge planning will begin on the day of admission and will be evidenced within the patient’s plan of care.

As soon as is practically possible, a discharge planning meeting should be organised by the hospital staff, involving the patient and should include the family/carers and the relevant hospital and community/primary care staff to identify:

• The potential date and time of discharge in order to plan the recommencing of normal daily activities, or recommended new care package; • Any potential difficulties the patient may experience on the day of discharge, such as waiting for lengthy periods in a discharge lounge; • The location and suitability of the environment to which the patient is being discharged; • Any other community/primary care staff who need to be informed of the patient’s discharge; • The support that the patient and the family/carers may require to help the patient remain within their own home environment (wherever home is); • Where certain procedures need to be carried out in the home environment after discharge, competency based training for families or other essential carers should be initiated and overseen in hospital prior to discharge taking place.

Careful consideration needs to be given to the admission/transfer/discharge planning, whether it is admission to a ward within the hospital, transfer to another hospital or discharge home. It is essential that time is taken to ensure that relevant information is passed on to other wards/departments/ hospitals and healthcare professionals. Specific care needs to be taken to ensure that the individual and/or the carer(s) are familiar with and understand the discharge advice, including any medication, treatments or follow-up arrangements.’

16. The pneumonia guidance says clinicians should start antibiotic treatment with amoxicillin or doxycycline as soon as possible after establishing a diagnosis of community-acquired pneumonia.

Trust’s decision to discharge Mr L on 4 November 2023

17. Mr L was admitted to hospital on 30 October 2023 and discharged on 4 November 2023. In its response to Mrs K’s complaint the Trust said:

‘Throughout the admission, Mr L’s observations were normal, and he was not receiving any treatment or investigations that required him to remain an inpatient. He was reviewed by the physiotherapist who felt that he could be discharged home with his current four times per day care package. The physiotherapist also completed a referral for community therapy to support him to improve his walking at home. No equipment needs were identified at this time and Mr L was discharged back to his home address, where he lived with his mum and where family lived close by. Mr L was discharged from the ward safely with medication to take home, district nurse referrals and a follow up appointment was to be arranged.’

18. The records indicate the Trust had treated Mr L with antibiotic medication for mild community acquired pneumonia (a lower respiratory infection with minimal symptoms and low risk of complications which is often managed in the community with antibiotics) in line with the pneumonia guidance. The records indicate this aspect of his condition improved as a result of this treatment.

19. The records show his NEWS score was recorded as either 0 or 1 during the 6 observation assessments performed by the Trust in the 24 hours prior to his discharge home. Our adviser said this indicates he was physiologically stable and at low risk of a clinical deterioration during the period leading up to his discharge.

20. Our adviser said there is no evidence in the records to indicate the Trust inappropriately discharged Mr L on this occasion. The records support the view he did not require further inpatient care and was in a suitable condition to be allowed home.

21. Our adviser said there is no evidence to indicate the Trust did not take into account Mr L’s individual circumstances and needs during his inpatient care or when deciding to discharge him. The records show the Trust clinicians noted his learning difficulties and a detailed history was taken by the doctor from his family on admission and recorded in his notes. The records indicate the doctor listened to the family’s concerns and discussed the plans for his care. The records also indicate the physiotherapy team considered Mr L’s needs and circumstances when discussing his rehabilitation needs with his family at the time of his discharge.

22. Our adviser said the records support the view an appropriate plan of care was put in place for after his discharge. He was discharged back to his regular home care plan and the Trust made an additional referral to the district nursing team to provide support with his catheter. The records indicate the Trust requested his GP check his thyroid function in 6 weeks and plans were also made for ongoing physiotherapy at home.

23. We carefully considered Mrs K’s complaint and the supporting information she has provided. We acknowledge Mr L had to go back to hospital the day after he was discharged and that this was extremely upsetting for him and his family. We also considered the information in the records, the guidance and the advice we have received.

24. We found no evidence to indicate the Trust’s decision to discharge Mr L on 4 November 2023 was inappropriate. We found all the clinical information in the days leading up to the discharge was considered in line with the MUST, the discharge and the GAIN guidance and supported the view that he was well enough to be allowed home.

25. We found the Trust considered his individual needs and discussed this with his family before discharging him home. We found no evidence to indicate the plan of care put in place for after his discharge was inadequate or that his readmission to hospital the next day was due to failings from the Trust during this discharge.

Trust’s decision to discharge Mr L on 21 November 2023

26. Mr L was readmitted to hospital on 5 November 2023 due to concerns about his poor mobility and the impact this was having on his condition at that time. Following a further period of treatment he was discharged home by the Trust on 21 November 2023. Mr L could not stand or walk unsupported by this time and the ambulance crew had difficulty transferring him from the ambulance to his home and returned him to hospital due to concerns about his safety.

27. Our adviser said there is no evidence in the records to indicate the Trust’s decision to discharge Mr L was inappropriate on this occasion. The records support the view he did not require further inpatient care and was in a suitable condition to be allowed home with an increased home care package. The records indicate his NEWS scores were between 0 and 2 in the 12 hours prior to his discharge and the condition he was being treated for (mild low sodium) had improved following treatment.

28. Our adviser said the records indicate the Trust referred him for appropriate outpatient care. This included referral to the district nursing team for assistance with his insulin management and referral to his GP for an echocardiogram (ultrasound scan of the heart) and repeat blood and kidney function tests.

29. The records indicate Mr L was reviewed by the Trust physiotherapy and occupational therapy teams during this admission and they found his existing home care package was no longer sufficient to meet his needs. Due to his fluctuating mobility his home care package would need to be increased from one carer to two and additional equipment would be required to help support him with his mobility on his return home.

30. The records indicate the Trust discussed the plans and the additional care he needed with his family prior to his discharge. The records confirm the Trust was advised his increased home care plan was due to start on 21 November 2023. However the Trust discharged him before confirming he had an adequate provision of care in place at home to receive him or that the discharge environment was suitable for him.

31. We carefully considered Mrs K’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We found the Trust did not act in accordance with discharge guidance and the GAIN guidance on this occasion.

32. We think the Trust should have confirmed the increased care plan was in place and ready to receive him before sending him home. We think this led to the failed discharge and Mr L having to return immediately to hospital. We think this caused Mr L, his family and his carers considerable frustration and distress.

Discharge of 1 December 2023

33. Mr L was returned to hospital on 21 November 2023 and discharged on 1 December 2023. In its response to Mrs K’s complaint the Trust said:

‘In discussion with Mr L’s niece on 22 November 2023, it was decided that Mr L did not need any equipment to help him to stand, but that he would need an increase in the number of carers attending on each visit owing to his variable mobility. The subsequent referral for care reflected that two carers were likely to be required at each call. The therapists explained that another referral would be sent to the appropriate community therapy team to help improve Mr L’s mobility once at home.

It is noted that the therapist also informed the ward that they needed to book a stretcher to get him home. This was to avoid any issues with the ambulance crew not being able to transfer him once he was home. Physiotherapists went to see Mr L on 28 November 2023, but he declined therapy. He was discharged home on 1 December.’

34 Our adviser said there is no evidence in the records to indicate the Trust inappropriately discharged Mr L on this occasion. The records support the view he did not require further inpatient care and was in a suitable condition to be allowed home. The records show his NEWS score was recorded as 0 for several hours on 1 December 2023 and an echocardiogram had found no abnormalities with his heart function.

35. Due to the failure of the previous discharge and the acknowledgement that he required additional support to enable him to return home, the Trust communicated with the social work team on this occasion to ensure the increased care plan was ready to receive him and the environment was appropriate to meet his needs. The Trust ensured a stretcher was available to prevent a repeat of the difficulties the ambulance crew faced when attempting to transfer him previously. The records indicate the Trust put in place an adequate plan of care for after his discharge which included a referral for intermediate therapy in his home.

36. We carefully considered Mrs K’s complaint and the supporting information she has provided. We acknowledge Mr L had to go back to hospital again a few days after he was discharged and that this was extremely upsetting for him and his family. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate the Trust’s decision to discharge Mr L on 1 December 2023 was inappropriate.

37. We found the Trust considered all the clinical information in the days leading up to this discharge in line with the MUST, the discharge and the GAIN guidance and this evidence supports the view that he was well enough to be allowed home. We found the Trust considered his individual needs, checked the care was in place to receive him and the environment was suitable to ensure his increased needs could be met at home. The Trust discussed this with his family before discharging him home. We found no evidence to indicate the plan of care put in place for after his discharge was inadequate or that his readmission to hospital on 5 December 2023 was due to failings from the Trust during this discharge.

Discharge of 14 December 2023

38. Mr L was readmitted to hospital on 5 December 2023 and discharged on 14 December 2023. In its response to Mrs K’s complaint the Trust said:

‘Mr L was reviewed on the ward round at 10:40am on 11 December 2023 when the issues noted were as follows: lower respiratory tract infection (completed 5 days doxycycline, an antibiotic); type two diabetes; learning disability; hyponatraemia (lower than normal level of sodium in the blood. Mr L’s sodium was 132mmol/L – normal range is 135-145). His observations were normal, and he appeared well. It was documented that Mr L felt well and had done over the weekend, and that he was back to normal mobility. The need for physiotherapy and occupational therapy input was discussed and the plan remained that he was medically fit for discharge.

On 12 December, Mr L was reviewed and noted to be comfortable. He was still medically fit for discharge. The following day, 13 December, Mr L was reviewed on the ward round. His observations were normal and he was again noted to be comfortable. The plan was to continue with discharge planning.

On 14 December, Mr L was again reviewed by the medical team. At this time, his blood pressure was 103/65, but otherwise his observations were normal. He was alert, looked comfortable and there were no new concerns. An ambulance was booked for that day to take Mr L to a care home and he remained medically fit for discharge.

In conclusion, Mr L remained medically fit for discharge during this period and there is nothing documented in the medical notes to suggest that this was not the case on the day that he was discharged.’

39. Our adviser said there is no evidence in the records to indicate the Trust inappropriately discharged Mr L on this occasion. The records support the view he did not require further inpatient care and was in a suitable condition to be allowed to leave hospital and receive the ongoing therapy he required in a care home environment.

40. The records show his NEWS score was recorded as either 0 or 2 during the hours prior to his discharge indicating he was physiologically stable and at low risk of a clinical deterioration. The records indicate the Trust provided appropriate antibiotics to treat his lower respiratory tract infection and carried out several medical reviews before deciding to discharge him.

41. Our adviser said there is no evidence to indicate the Trust did not take into account Mr L’s individual circumstances and needs during his inpatient care or when deciding to discharge him. The records indicate Mr L was reviewed by the Trust’s clinical, physiotherapy and occupational therapy teams on several occasions before being discharged. The Trust noted his mobility needs and the additional support he required with eating, drinking and repositioning in bed in preparation for his discharge.

42. The records indicate the Trust considered Mr L’s needs and circumstances and discussed his ongoing therapy with his family. The record of the discussion with the family on 12 December 2023 notes the concerns the family raised about Mr L’s needs and their view he would benefit from further rehabilitation care. On this occasion the Trust discharged Mr L to a care home.

43. We carefully considered Mrs K’s complaint and the supporting information she has provided. We acknowledge Mr L had to go back to hospital in the early hours of the following day after suffering a sudden deterioration in his condition and we understand how upsetting this was for his family. We also considered the information in the records, the guidance and the advice we have received.

44. We found no evidence to indicate the Trust’s decision to discharge Mr L on 14 December 2023 was inappropriate. We found the Trust considered all the clinical information in the days leading up to the discharge in line with the MUST, the discharge and the GAIN guidance and this evidence supports the view that he was well enough for his ongoing care to be provided to him in a care home environment.

45. We found the Trust considered his individual needs and discussed this with his family before discharging him. We found no evidence to indicate his readmission to hospital on 15 December 2023 was due to failings from the Trust during this discharge.

Failure to investigate and diagnose pulmonary embolism

46. Mr L was taken to A&E at the Trust in the early hours of 15 December 2023 after the care home staff found he had been coughing up blood. Mr L sadly died at 9.30pm on 15 December 2023. There was no post-mortem examination performed to establish the precise cause of Mr L’s death. However the presumed cause shared with Mrs K by the Trust in the days after he died, and the cause recorded on the death certification summary in the records, was pulmonary embolism (PE).

47. Mrs K says the Trust failed carry out the appropriate investigations to diagnose the PE which led to her brother’s death. She says if the Trust had identified this and provided appropriate treatment his condition may not have deteriorated and he may not have died.

48. A PE is a serious condition caused by a blood clot that has broken away from a clot in another part of the body and travelled to the lungs, blocking the blood vessels in the lungs. This is a life-threatening condition due to the impact it has on reducing the blood flow to the heart and lungs.

49. A PE can appear suddenly, often within seconds or minutes of a blood clot lodging in the lungs. The transition from a localized blood clot in the body to a life-threatening lung blockage can be very quick and symptoms including shortness of breath, sharp chest pain and coughing up blood can appear without warning. This sudden onset is due to the way a blood clot breaks away from its original location and is carried quickly through the bloodstream to the lungs, leading to a blockage in the pulmonary artery (the artery that carries blood from the heart to the lungs for oxygenation).

50. The PE guidance says the treatment to prevent against PE is 2.5mg of anticoagulant medication twice a day. The records indicate Mr L was diagnosed with heart failure in July 2016 and his resulting care plan included 5mg of anticoagulant medication (apixaban) twice a day to reduce the risk of blood clots and PE. The records indicate the Trust continued Mr L’s apixaban medication during each admission between October and December 2023.

51. Following his attendance on 15 December 2023 the Trust noted he had been brought to A&E due to coughing up blood. The Trust’s Initial examinations identified unilateral chest crackles (which can indicate various underlying conditions such as infections, heart failure or other respiratory issues) and a productive cough with brown sputum.

52. The Trust performed blood tests which identified an elevated white blood cell count (an indication of an infection) and mildly elevated level of C-Reactive Protein (a protein released by the liver in response to inflammation, infection, or tissue injury). The Trust performed a chest X-ray which reported his lungs and pleural spaces (the areas surrounding each lung) were clear. As a result of these findings the Trust diagnosed a chest infection and started treatment with intravenous antibiotics and fluids.

53. Our adviser said the clinical findings in the records are in keeping with a diagnosis of chest infection, even in the presence of the normal chest X-ray (a chest X-ray can often show as normal in cases of chest infection). Our adviser said the investigations carried out and the treatment provided by the Trust was appropriate for his clinical presentation during this admission.

54. Our adviser said the records confirm Mr L was already being treated with anti-coagulation medication as a precaution against blood clots and PE and the Trust continued this treatment during this admission. Our adviser said there is no evidence in the records we can point to which would indicate a PE was evident prior to his death.

55. We carefully considered Mrs K’s complaint and the supporting information she has provided. We acknowledge how upsetting this incident was for her and her family. We also considered the information in the records, the guidance and the advice we have received.

56. We found no evidence to indicate the Trust failed to carry out the appropriate investigations or provide the appropriate treatment for PE following his admission on 15 December 2023. We found there was no evidence prior to his death that PE was the cause of his condition or that it was a clear diagnosis that should have been made by the Trust but was missed.

57. We found the Trust provided treatment consistent with his clinical presentation at the time. In addition to this, the Trust also provided appropriate anti-coagulant treatment to reduce the risk of PE throughout the full period of care as it was already part of Mr L’s regular medication regime.

58. We acknowledge that there was no post-mortem examination carried out to confirm the precise cause of Mr L’s death and this would have been helpful in giving the family clarity which we cannot now provide. We also acknowledge the cause of death recorded by the Trust of PE was done in retrospect and based on the best available clinical evidence at the time.

1. We partly uphold this complaint. We partly uphold a complaint when we have identified failings in some aspects of care but not in others.

2. We found the Trust inappropriately discharged Mr L on 21 November 2023 without confirming the increased care plan was in place at his home. We did not find any failings in the other aspects of care complained about.

59. We make recommendations in line with our Principles for Remedy which are reflected in the NHS Complaint Standards. These say organisations should identify instances where things have gone wrong, take responsibility for these and find ways to put things right for those involved. They should learn from complaints to improve services.

60. We have identified failings in the Trust’s decision to discharge Mr L on 21 November 2023. We think this led to the failed discharge and his immediate readmission to hospital the same day.

61. With that in mind, we recommend the Trust writes to Mrs K to: • acknowledge the failings we have identified and apologise for the impact they had • explain what action it will take, or has taken, to address these failings – it should do this in the form of an action plan which should be shared with us, the complainant, and the Care Quality Commission.

62. The Trust should send this to Mrs K within one month of the date of our final report. The Trust should send us evidence it has completed all of the recommendations we have made. We will check the action plan includes the reason for the failing, what the organisation does or will do differently in future, who is responsible for each action, the timescale for completion, and how it will be monitored.