Harrogate and District NHS Foundation Trust

3. Mrs A complains about aspects of the care and treatment her husband, Mr A, received from the Trust between August and September 2024. Specifically, that the Trust: • used a CPAP mask even though her husband was nauseous and had Parkinson’s disease • incorrectly discharged her husband twice on in September 2024.

4. Mrs A believes because of the Trust gave her husband the CPAP mask, he inhaled vomit severely impacting his health. She also believes as the Trust discharged him too soon this caused his health to deteriorate. Mrs A is concerned both issues caused or contributing to his death. Mrs A says she endured a distressing and avoidable experience. She also says the suffering and loss of her husband caused her a great deal of distress.

5. As an outcome to her complaint, she is seeking service improvements from the Trust.

6. Mr A was 79 years old, had Parkinson’s disease and poor mobility. He also had sleep apnoea so used a CPAP machine when he was sleeping to keep his airway open.

7. A CPAP (Continuous Positive Airway Pressure) machine is used to treat sleep apnoea by providing a constant flow of air to keep the airways open during sleep.

8. The Trust admitted Mr A to hospital in August 2024 for elective hip replacement surgery. The Trust performed the surgery successfully and without complications. Mr A’s immediate post-operative recovery was slow.

9. At the end of August (seven days post-surgery) at around 6am Mr A vomited while he was still on the CPAP machine. This meant he vomited into the facemask he was wearing. Mr A subsequently developed aspiration pneumonia. Aspiration pneumonia is a type of lung infection that happens when food, drink, or saliva accidentally goes down the wrong way into the lungs instead of the stomach, causing irritation and infection.

10. Mr A remained on the orthopaedic ward, he received multidisciplinary care, including input from the medical team and critical care.

11. Before the Trust discharged Mr A his wife raised concerns as she believed he was unfit for discharge. Mrs A told staff she was concerned her husband’s legs were still very swollen.

12. Staff discussed Mrs A’s concerns with her and told her the swelling was likely to improve when Mr A started to mobilise properly.

13. The trust discharged Mr A from hospital in early September.

14. The next day Mr A attended A&E. Mrs A complained he had excessive drowsiness. Staff assessed him and discharged him home with antibiotics.

15. Several days later Mr A fell out of bed at home, and an ambulance took him to a different hospital. Staff were concerned about his condition and admitted him to their respiratory ward for treatment.

16. Mr A sadly passed away just over two weeks later.

Decision to use a CPAP mask

20. Mrs A complains that staff put the CPAP machine on her husband although he had mentioned feeling nauseous and had Parkinson’s disease. She believes the more immediate risk of choking was not prioritised over the possible longer-term effect of not using the CPAP device for a short period.

21. GMC Good practice in proposing, prescribing, providing and managing medicines and devices outlines key principles for clinicians when using medical devices such as a CPAP machine.

22. It highlights the importance of assessing the patient’s needs, involving them in decision-making, prescribing medicines and devices responsibly, ensuring safe and effective management (including monitoring and reviewing), keeping clear records, and acting promptly if issues arise.

23. The guidance sets out that it would typically be appropriate to continue using a CPAP machine in hospital if the patient normally uses one at home, if it is safe to do so. For Mr A, there was no clinical reason why he could not use a CPAP machine, and he had demonstrated regular use of it in the past.

24. The records indicate that Mr A did not use the CPAP machine every night after his surgery. Medical notes made at the time show on some nights he made the decision not to wear the CPAP mask. This shows that he was able to indicate when he did not wish to use the machine.

25. Staff updated information on Mr A’s condition regularly. These notes included information about his NEWS and presentation. The notes also contain regular mention of his Parkinson’s. We have seen evidence staff considered this when making any decisions about his ongoing treatment.

26. A Trust would use the NEWS to assess a patient by regularly measuring vital signs, such as heart rate, respiratory rate, and oxygen saturation, and assigning scores to identify any signs of deterioration, prompting timely clinical responses if needed.

27. Our orthopaedic adviser confirmed a person having Parkinson’s would not exclude them from using a CPAP machine. As above, Mr A had already been using one regularly before his admission to hospital.

28. We recognise there were times when Mr A had reported feeling nauseous. However, his records show Mr A did not report feeling nauseous before he went to sleep that night. This indicates when staff made the decision that it was safe for Mr A to use his CPAP machine overnight they did so as he was not reporting that he felt any nausea at the time.

29. We understand Mrs A’s concern that her husband vomited while wearing the CPAP mask. This must have been a very distressing time for both Mrs A and her husband.

30. We have seen no indications of failings in relation to the Trust’s decision to use a CPAP machine.

The Trust incorrectly discharged Mr A on two occasions

31. Mrs A told us she believed the Trust discharged her husband twice when he was clearly ill. and given no further support other than a short course of antibiotics. Mrs A says she believes this was an inadequate response to his condition at the time.

First discharge from hospital

32. The Trust’s decision to discharge Mr A after his longer admission was based on a doctor’s clinical judgement. Observations completed before discharge were normal with a NEWS of 0.

33. We know Mr A had developed aspiration pneumonia while he had been in hospital. The Trust treated this with antibiotics prior to discharge.

34. NHS England’s Hospital discharge and community support guidance sets out that once it considers a person for discharge, the Trust must ensure that the discharge process is safe, person-centred, and well-planned.

35. It also says the Trust should ensure the patient’s GP receives updated information, such as discharge summaries, care plans, or recommendations for future treatment. This is because the GP is typically the primary point of contact for managing a patient’s ongoing healthcare needs.

36. On discharge the Trust referred Mr A for an outpatient appointment for some further tests on his heart.

37. It also sent his GP information about his ongoing care needs. This included a request for his GP to review the results of the outpatient test and conduct any further tests they may wish to. This information also confirmed the Trust had prescribed medication for aspiration pneumonia, and Mr A had completed the course during his admission.

38. Before discharge Mrs A raised concerns that Mr A’s legs were still very swollen and she was concerned he was not fit for discharge.

39. The discharging doctor documented Mrs A’s concerns. They set out that they had considered the swollen legs and arranged a follow up review of his heart. They confirmed the clinical team were happy to discharge Mr A with follow up care. They also advised that should Mr A develop shortness of breath or chest pain he should attend the emergency department as soon as possible.

40. Our orthopaedic adviser confirmed the discharge was clinically appropriate in line with the Hospital discharge and community support guidance as there was no medical necessity to keep Mr A in hospital.

41. NICE guidance on the Transition between inpatient hospital settings and community or care home settings for adults with social care needs says the Trust should provide carers, such as Mrs A, with information and support.

42. This guidance supports the principle that discharge should be based on whether the person's needs can be safely met outside hospital, not on full recovery. So, although Mrs A does not think Mr A had fully recovered from the aspiration pneumonia, this would not prevent his discharge.

43. As set out above the discharging doctor provided information in line with this guidance. They had a face-to-face discussion with Mrs A and her son to address the concerns they raised. They also provided the relevant information in a discharge letter and provided this information to Mr A’s GP.

44. We have seen no indications of failings in relation to Mr A’s initial discharge from hospital. We understand Mrs A remains concerned about this discharge so hope she finds this decision helpful.

Discharge from A&E

45. Mr A attended A&E the day after his initial discharge. Mrs A told staff that he was excessively drowsy after being treated for aspiration pneumonia while in hospital.

46. The doctor noted Mr A’s past medical history and recent discharge. They also noted the Trust discharged him with resolving pneumonia and arranged further follow up.

47. Staff completed observations and noted Mr A’s NEWS was 1. A NEWS of 1 typically indicates a mild deviation from the normal range in one of the patient's vital signs, which usually requires monitoring but not an urgent clinical response.

48. Mr A’s GCS was 15/15. The GCS is used to assess and monitor a person’s level of consciousness. A GCS score of 15/15 indicates that a person is fully awake, alert, and responsive.

49. GMC Good medical practice sets out the doctor must provide a good standard of practice and care when they assess, diagnose, or treat patients.

50. The attending doctor assessed the patients’ condition, considering their history. They also carried out a physical examination and prescribed antibiotics. Therefore, the records indicate the doctor completed this in line with the GMC Good medical practice.

51. The RCEM ‘Best Practice Guidance on Patient Care’ provides a checklist of care initiatives directed at improving patient experience and the quality of care given to patients within the Emergency Department. Point 25 of the guidance sets that safety netting advice should be given. It also sets out diagnosis and symptom management should also be given.

52. On discharge the doctor made a diagnosis of a lower respiratory tract infection and prescribed antibiotics. They also provided safety netting advice. They also sent a letter to Mr A’s GP with follow up plans. The doctor completed this in line with the RCEM Best Practice Guidance on Patient Care.

53. We have seen no indications of failings in Mr A’s care in relation to his discharge from the A&E department.

54. We understand Mr A had to return to hospital a few days later and are sorry to hear following his discharge his condition continued to cause concern. We recognise Mrs A is unhappy with aspects of the care and treatment Mr A received and understand it was a worrying time for her.

55. We have seen no indication that anything went seriously wrong in the care and treatment the Trust provided to Mr A. As such, we have decided to take no further action on Mrs A’s complaint. We hope our decision provides some reassurance to her about the care and treatment Mr A received.

1. We have carefully considered Mrs A’s complaint about the Trust. We have seen no indications that there were failings in the care the Trust provided. As this is the case we will take no further action.

2. We were sorry to hear Mrs A’s concerns about her husband’s care and we hope our decision, which we explain in this statement, provides some reassurance for her. We were very sorry to hear about what Mrs A had been through and sympathised with her for her loss.