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Hospital’s ‘unwieldy’ discharge policy left GP without vital patient information

A coroner has deemed a private hospital chain's discharge policy ‘lengthy’ and ‘unwieldy’, which left GPs short of vital information, following the death of a 55-year-old woman.

In a report aimed at preventing future deaths, Cheshire's coroner criticised Nuffield Health's discharge policy after staff failed to send information to the patient’s GP or any request to conduct a follow-up blood test - and the patient went on to develop a ‘dangerously low’ platelet count.

Coroner Claire Welch concluded that although the death of Mary Chapman was not caused by the lack of follow-up blood test, ‘ongoing uncertainties’ in the discharge process could lead to future deaths.

Ms Chapman died on 4 March 2018 from a large myocardial infarction, a left descending coronary artery thrombosis and a catastrophic antiphospholipid syndrome.

She was discharged from Chester's Nuffield hospital on 16 February 2018 following an elective knee replacement, but tests showed her blood platelet count was 74, meaning she needed a follow-up blood test.

However, the coroner outlined that due to multiple problems occuring as Ms Chapman was being discharged by the hospital, doctors and nurses did not document the need for a follow-up blood test in the discharge summary.

They also did not tell the patient or write directly to the GP, and also failed to let the GP know about low platelet count.

Ms Chapman went on to be re-admitted to the same hospital almost two weeks later with a ‘dangerously low’ platelet count of 7 and eventually died of natural causes, Ms Welch concluded.

The coroner criticised the discharge policy used across the private organisation's hospitals.

She said: 'Although a Nuffield-wide "discharge policy" has been created, the document is lengthy, unwieldy and generic.

'It does not clearly define who is responsible for doing what, or when, as part of the discharge process and there is no clear local or Nuffield-wide guidance document or policy that achieves this.’

She added: '‘There is no clear local or Nuffield-wide guidance document or policy on how the need for critical post-discharge investigations should be arranged or communicated, or by whom or when.’

Since Ms Chapman’s death, the coroner said that there is no evidence changes has been made by Nuffield Health - a statement the private hospital group disputes.

The coroner's report, dated 8 October 2019, said: ‘Despite 18 months having elapsed since the death, there was no evidence at the inquest to demonstrate that such changes as have been implemented have improved the quality, accuracy and robustness of discharge communications.’

But a spokesman for Nuffield Health said the hospital undertook its own investigation after the death of Ms Chapman and has rolled out clearer discharge policies.

They said: 'Our own investigation immediately after the death of the patient led to improvements implemented at the hospital and rolled out across our network.

'We have informed the coroner that we have implemented clearer discharge policies for all multidisciplinary team members across our 31 hospitals nationwide.

'Patient safety is our first priority and we continuously seek to improve the care we provide.'

Coroners elsewhere have criticised hospital discharge procedures, with one in Liverpool saying that discharge letters should be sent not just to GPs but all medical attendants in primary, secondary, and tertiary care.

Readers' comments (4)

  • Once again it highlights the work dump by hospitals and the lack of staff both in hospital and in primary care.
    Instead of limiting work and encourage a learning environment, letting us focus on clinical things, they dump social problems, organisational, re-organisational problems, pension problems etc on us.
    Doing more is not necessarily better as it shows. Time for BMA to say no. Less is more in this case.

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  • Platelet count of 74- what I want to know is 1. was this pre- or post-op? 2.Does she have any previous platelet counts documented including in the GP record? 3.If she does, what were they?

    I would not be at all surprised if she had a niggling low-level thrombocytopenia for some time which the GP had not bothered to think about critically. I would love to be wrong but I have seen anti-phospholipid syndrome with low platelets missed/ignored until the retrospectoscope comes out when the patient has a DVT on more than one occasion.

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  • Why should Nuffield have any better discharge procedures than an NHS hospital?
    Most of our discharges are close to this.

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  • Reviewed a discharge summary today, elderly chap chest pain significant coronary artery disease found, for medical management

    In the GP action box - someone had verbatim cut and paste the entire NICE guidance on secondary prevention for CVD. In a tiny font.

    What pointless rubbish.

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