Hospital discharge procedures were recently highlighted in a Parliamentary and Health Service Ombudsman (PHSO) report that revealed vulnerable patients in England were being sent home before they were clinically ready to leave hospital.
The report pinpointed poor planning, co-ordination and communication as key factors contributing to the unsafe discharging of patients. It also found cases where clinicians failed to properly assess or consult patients before their discharge as well as incidents where relatives and carers were not informed that their loved ones being released from hospital.
Furthermore, a Healthwatch England report from last year found that nearly a fifth of patients discharged felt they did not have the support they needed after leaving hospital, while one in eight patients felt unable to cope at home, leading many to be readmitted.
MDDUS has assisted members with a number of cases involving inappropriate discharging of patients. These range from patients who have had to be readmitted to hospital to more serious incidents in which patients have died shortly after discharge.
We have also seen numerous cases where breakdown in the continuity of a patient’s care or the absence of relevant information in a discharge form has resulted in patient harm.
One example involved a medication being stopped but with no reason or explanation recorded on the discharge form. This resulted in the patient still receiving the omitted medicine as part of their repeat prescription from the local practice.
Similarly, we have encountered cases in which patients have not been followed-up in the community following a new diagnosis or abnormal test result because it has either been omitted from the discharge form or was illegible.
As the PHSO report highlights, when a patient is discharged from hospital, doctors must be satisfied that they are not only medically safe to leave hospital, but they feel supported with appropriate information and advice on follow-up support and home-care plan if needed. The discharging process should be robust to minimise the risks of adverse events.
Communication with GPs
A careful and thorough discharge is particularly important in patients with complex medical needs or unresolved issues. In these cases, hospital doctors should contact the patient’s GP to ensure the patient receives continuity of care once they are discharged back into the primary care setting.
The accurate and legible completion of a discharge form is a vital element of the overall discharge process and provides a crucial link between secondary and primary care. Discharge forms are often the only piece of information a GP has on a patient’s hospital care and treatment.
Poor communication between different departments is a common factor in clinical negligence and regulatory actions encountered at MDDUS. Crucial information can be missed in a busy setting so proper procedures must be followed.
While many problems arise when patients are discharged either too early or without the appropriate follow-up support in place, MDDUS has also encountered cases in which complications have arisen following delayed discharge as a consequence of poor co-ordination or communication across services. For example, patients with complex needs may face lengthy delays in finding suitable care packages.
What should GPs do?
If a GP feels that their patients have been either inappropriately discharged, or discharged without adequate communication with the practice, they should take immediate steps to ensure patient safety is not compromised.
This may involve asking the patient to attend the practice, visiting the patient at home and/or contacting the hospital to discuss the discharge plan and follow-up arrangements.
GPs are entitled to request as much information as they require from secondary care to satisfy themselves that their patient can be managed safely and effectively in the community.
Practices themselves should have a sound system in place for handling patients discharged from hospital and requiring further care. To help ensure they have all the information they need, practices should:
- Decide whether any request has been reasonably forwarded to the practice for action, e.g. is it within their scope of work and competence?
- Diarise any outstanding actions – either in a regularly reviewed diary system or an alert on the patient record
- Alert the patient to the follow up/action and expected timescale where appropriate
- Where action is required directly in the practice (e.g. a blood test or follow up appointment), then record in the appointment slot, the source of the request and the reason for it.
Dr Nazem is a medical adviser at MDDUS