Failings in hospital discharge process led to development of serious pressure ulcer

What happened

Mr Y was admitted to hospital in early 2013. Staff considered that he was medically fit for discharge a month later. His wife was certain she would be unable to care for him at home and so refused the proposed care package, hoping this would delay the discharge. However, Mr Y was still discharged and spent up to seven hours in the discharge lounge before he was taken home by ambulance. He was unable to walk into his house unaided and then slept in a chair at home for the next 36 hours.

After Mrs Y spoke to her GP, Mr Y went back to hospital, where staff found that he had developed a large pressure ulcer at the base of his spine. Mr Y stayed in hospital for another six weeks before he was discharged to a nursing home. Sadly he died three weeks later. Mrs Y said a nurse told her that the pain from her husband's pressure ulcer caused his heart failure.

Mr Y's wife complained but was unhappy about the Trust's first response. After her daughter–in–law met the Trust, it arranged for a review of Mr Y's care. The review identified several flaws in the Trust's first response and concluded that staff should not have discharged Mr Y without first investigating his wife's concerns. The Trust apologised to Mrs Y for letting her and her husband down by 'inappropriately' discharging him and for mistakes in its initial response.

Mrs Y remained unhappy and asked her daughter–in–law to bring the complaint to us.

What we found

We partly upheld this complaint. We agreed with the Trust that it was inappropriate to discharge Mr Y. We also agreed there was no evidence he received any care during his time in the discharge lounge. We were satisfied there was no indication he needed pressure area care before his discharge.

However, on balance, the inappropriate discharge was a significant factor in the development of Mr Y's pressure ulcer because Mr and Mrs Y had no support at home so Mr Y was not moved for 36 hours. There was a slight delay in giving Mr Y appropriate pressure care when he was readmitted but otherwise the pressure care he received throughout the rest of his admission was reasonable.

The nursing and medical advice we received clearly told us that the pain from Mr Y's pressure ulcer would not have been a significant factor in his heart failure.

Putting it right

The Trust gave Mrs Y a further apology for the consequences her husband experienced as a result of the inappropriate discharge decision. It also paid her £750 compensation.

The Trust agreed to create an action plan to identify and address any learning from this complaint to try and prevent similar circumstances occurring again.