Decision Report 201600431

Summary

Mr C complained about the care and treatment provided to his late father (Mr A) while he was a patient at Aberdeen Royal Infirmary. Mr A had a complex medical history and he was admitted to hospital with ischemia (inadequate blood supply to an organ or part of the body) and sepsis (a blood infection). Several weeks later, he was discharged to a community hospital from where he was discharged home. He died the following day. Mr C complained about aspects of Mr A's discharge to the community hospital including communication.

We took independent medical advice. We found an unreasonable failure by staff to carry out comprehensive multi-disciplinary discharge planning. We also found that Mr A was transferred to a community hospital when he did not have capacity, which was against his family's wishes and without relevant documentation. We also found that there had been a breakdown in communication which meant that medical staff wrongly informed other staff about the family's wishes in relation to discharge. We upheld the complaint.

Recommendations

We recommended that the board:

• review what happened in light of the adviser's comments and reflect on relevant guidelines to ensure that processes in relation to discharge of complex patients are adequate;
• bring the failings identified to the attention of relevant staff; and
• apologise for the failings identified in this investigation.