Hospital wrongly discharged vulnerable 84–year–old patient to empty house

What happened

Mrs F was admitted to hospital because of a urine infection. Staff gave her antibiotics. Her consultant said that she should stay in hospital for three more days so she could have more antibiotics and staff could monitor her. She was then to be discharged. For reasons that are unclear, Mrs F was discharged later the same day.

When Mrs R realised that her mother had been discharged, she asked a neighbour to check on her. The neighbour was worried about Mrs F because she seemed confused and still had a catheter in place. Mrs R spoke to the ward sister, who was concerned about why Mrs F had been discharged and who had arranged this.

The ward sister explained that Mrs F's medical notes were not fully completed, and she should not have been discharged, especially with a catheter still fitted, and with no medication.

An ambulance returned Mrs F to hospital, where she received appropriate treatment.

Mrs R complained about her mother being wrongly discharged from hospital. The Trust accepted that the discharge was inappropriate, and said that there was no documentation about Mrs F's discharge or who arranged/ authorised it. The Trust said that it could not get to the bottom of how or why Mrs F had been discharged.

Mrs R was dissatisfied with the Trust's responses. She did not feel it had got to the root cause of what had happened, and had not made any changes to its discharge processes.

What we found

It was wrong to discharge Mrs F against the instructions of the consultant, and when she had a catheter in and no discharge medication. A doctor must have authorised the discharge, and instructed a member of nursing staff to arrange it. There is no documentation by either the doctor or nurse about this decision to discharge Mrs F. This was a failure to comply with Nursing and Midwifery Council standards about record keeping. The situation could have had very serious consequences for Mrs F.

The Trust had already taken a number of actions as a result of the complaint, including apologising for the distress caused, and discussing the incident at the relevant team meeting, at the ward manager's meeting and at the medical directorate physician's meeting, so that staff could learn from what happened. However, more should have been done to give reassurance that this could not happen again.

Putting it right

The Trust apologised to Mrs R for not taking enough remedial action as a result of her complaint.

It produced an action plan, setting out changes to be made to the discharge process. It also agreed to audit compliance with its electronic discharge notification process, and to take action if staff did not comply with the process.