Decision Report 202307865

Summary

C complained about the care and treatment provided to their parent (A) in relation to a number of hospital admissions. C complained that A was discharged without clear advice as to whether they had sepsis, and how to manage A’s condition. C also said that the board did not provide a discharge letter. C complained that when A attended hospital four days later, they should have been admitted rather than being sent home with oral antibiotics. Lastly, C said that when A was readmitted to hospital the following month, a day passed before they were seen by a consultant.

We took independent advice from a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs). We found that, while A received appropriate care during their initial admission, the board's communication around A's sepsis was unreasonable. They also did not provide an interim discharge summary.

In relation to A's second discharge, we found that A's symptoms raised the possibility of a complicated kidney infection. Therefore, we considered that discharging A with oral antibiotics was unreasonable. A should have received treatment with IV antibiotics and consideration should have been given to admission, which may potentially have prevented the need for A to be admitted the following month. We upheld these parts of C's complaint.

Finally, we found that A's condition when they were readmitted did not meet the criteria for an urgent consultant review. Therefore, we did not uphold this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Decisions on admission and treatment with IV antibiotics should be in keeping with European Association of Urology (EAU) guidelines on Urological Infections and The UK Health Security Agency guidance on antimicrobial intravenous-to-oral switch (IVOS) criteria for prompt switch for adults.
• Immediate discharge letters should be issued at the time of discharge and patients and where applicable their families, should receive appropriate advice on discharge which should be documented in the patient’s medical records.
• Patients with sepsis and their family members and carers should be given opportunities to ask questions about a diagnosis, treatment options, prognosis, and complications. There should be a willingness to repeat any information as needed.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.