The investigation identified that Mr A was a complex patient who did not receive the multi-team input he needed prior to his discharge.
The Health Board agreed to apologise to Mr A for its lapse in care. In addition, in order to prevent any similar future occurrences, the Health Board agreed that within 3 months it would put in place the following arrangements: • Prior to a step-down in a level of care, complex patients should have a multi-disciplinary meeting, with each specialty’s responsibilities clearly outlined in an easily visible shared care document.
• Prior to discharge, complex patients should have a multi-disciplinary meeting, with each specialty providing their views in an easily visible shared document.