Failings in care and communication did not cause death of woman in her late seventies

What happened

Doctors decided that a chest infection was making Mrs F's chronic obstructive pulmonary disease worse, so they treated her with antibiotics. Over the next few days they noticed Mrs F had swollen ankles. A chest X-ray showed fluid overloading in her lungs. Trust staff prescribed furosemide (a drug which reduces fluid retention) five days into the admission and did a blood test, which confirmed Mrs F had heart failure.

Trust staff discharged Mrs F two days after they had prescribed furosemide and one day after the heart failure diagnosis. Her GP saw her two days later and prescribed another drug similar to furosemide. Mrs F deteriorated and was readmitted to hospital five days after she had been discharged. She was treated in the intensive care unit and  died three days later.

Mr T, Mrs F's son, complained that his mother had not been fit for discharge. He said she had eaten very little, did not produce much urine, could not lie down comfortably and had swollen legs. Mr T also complained that communication about Mrs F's condition was poor and staff did not tell her family she had heart failure.

Mr T said that if the family had had full knowledge of the facts and his mother had received good care, she might not have died. He wanted the Trust to acknowledge that the care it gave was substandard and the decision to discharge his mother was wrong.

What we found

There were failings in care and communication. We noted that staff discharged Mrs F before her fluid balance had stabilised on the furosemide. This was contrary to guidelines on the care of patients with heart failure. We also saw no evidence that staff told Mrs F or her family about her heart failure. The Trust should not have discharged Mrs F unless she and her family agreed to this in full knowledge of her condition, her care needs and what to expect. We do not believe that this was the case.

We did not conclude that Mrs F died as a result of the failings. If she had remained in hospital, doctors would have responded to her deteriorating condition slightly sooner but it is very unlikely that this would have made a difference to the sad outcome.

We do not believe that Mrs F would have lived any longer if she had stayed in hospital. However, the inappropriate discharge caused her family anger and distress and made them question whether her death was avoidable. The situation was made worse because Mrs F's family did not know about her heart failure diagnosis and were not aware of how serious her condition was.

Putting it right

The Trust wrote to Mr T apologising for the failings we identified. It drew up an action plan that detailed how it will improve communication with patients and their families.