• Case ref:
  • Date:
    April 2019
  • Body:
    Lothian NHS Board - Acute Division
  • Sector(s):
  • Subject:
    admission / discharge / transfer procedures
  • Outcome:
    Upheld, recommendations


Ms C complained that her father (Mr A) was inappropriately discharged from the Royal Infirmary of Edinburgh. Mr A had poor balance and mobility and had expressed his concerns about his ability to cope at home. Mr A fell shortly after discharge. After a number of hours, he managed to get help and was taken back to the hospital. Mr A was kept in hospital for another month due to a suspected infection.

We took independent advice from a nurse and a clinical adviser. We found that there had been a lack of discharge planning as to whether or not Mr A could safely cope at home and whether he required the assistance of carers or someone to stay with him. We also found that there were signs in the medical records which may have indicated that Mr A may have had an infection prior to discharge and that the signs were not acted upon. We upheld Ms C's complaint.


What we asked the organisation to do in this case:

  • Apologise to Mr A for the failure to accurately determine if he was clinically fit for discharge and that there was a lack of discharge planning into whether he could cope at home. The apology should meet the standards set out in the SPSO guidelines on on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

  • Clinical and nursing staff should ensure prior to discharge that an appropriate clinical assessment has been carried out. In addition that adequate consideration is given as to whether the patient is able to care for themselves on discharge.