Patient discharged from A&E was readmitted later that day

What happened

A community hospital had been treating Mr F for a chest infection. When he developed breathing difficulties, he went to the Trust's A&E. Doctors suspected he had had a heart attack.

After Mr F had been in A&E for several hours, the Trust decided that he had not had a heart attack and discharged him back to the community hospital. Shortly after he arrived, his condition deteriorated and he was rushed back to A&E, from where he was admitted to hospital

Mrs F complained that Mr F was not properly monitored or assessed during his first A&E visit. She said doctors did not recognise how serious his condition was and nurses did not properly look after him. She blamed the Trust for his deterioration and his subsequent emergency admission, which she said could have been avoided if staff had correctly judged whether Mr F was fit enough to be discharged.

She also complained that the Trust did not tell the community hospital about what investigations and treatment it had given Mr F, or what his treatment plan was after his discharge.

What we found

Nurses at the Trust did not carry out enough tests, and when they found an abnormality, they did not tell the clinician. The clinician did not do a proper risk assessment of Mr F, and this probably caused his deterioration after his discharge.

The Trust did not give the community hospital enough information about Mr F's treatment plan after his discharge.