Inappropriate discharge of terminally ill patient caused patient and family distress

What happened

Ms P went into hospital with severe abdominal pain. She was treated for constipation and discharged home two days later.

Ms P's family explained that she was too ill to manage the stairs at home so she had to spend the night on the sofa. The next day her partner contacted a hospice for advice as he was so concerned. A nurse from the hospice attended and told them to call for an emergency ambulance to take Ms P back to hospital. She died a few days later.

What we found

Ms P was known to have an existing hemiparesis (a weakness of one side of the body) caused by metastatic disease. She was also known to the oncologists at the Trust. However, there was no assessment of her disability or deterioration in her disease status. The nursing staff also failed to properly assess whether she could manage at home.

Ms P was unable to cope at home and had to spend the night on a sofa because she could not manage the stairs. Although she was taken back to hospital by ambulance the next day and she died shortly after, we could not link the failings to the subsequent decline in her health. However, the failings caused considerable distress to Ms P and her family, who had to look after her at home and witness the distress she was in.

The failings were exacerbated by poor complaint handling by the Trust. It took too long to respond and its responses were not sufficiently detailed and did not give assurances that action would be taken to put right any failings.

Putting it right

We recommended that the Trust formulate an action plan to address the failings identified in our report and prevent similar situations happening again. We also recommended that the Trust apologise for the failings in its handling of this complaint and make a financial payment of £750 for the distress caused to Ms P and her family because of the failings.