Failure to follow up after hospital discharge

One area of risk on the patient journey is the interface between secondary and primary care. 

Ms D, a 79-year-old woman, underwent a total hip replacement under consultant orthopaedic surgeon Dr R.  Although the surgery went well, she experienced poor appetite and occasional vomiting afterwards. Routine postoperative blood tests demonstrated a low serum sodium level at 128, and a mildly elevated C-reactive protein.

However, her condition slowly improved and Dr R was happy for her to be discharged on day four post-procedure. The resident medical officer, Dr B, advised her to arrange follow up blood tests with her GP. The abnormal results were not communicated to Dr R or highlighted in Ms D’s discharge summary.  
 
Four days after her discharge, Ms D attended her GP requesting an appointment for follow-up blood tests, as advised. As no urgency had been conveyed by Dr B, the blood test appointment was scheduled for two weeks later.
 
Twelve days after her discharge, Ms D was found collapsed and confused at home by her niece, who called an ambulance. She sustained a cardiac arrest in the ambulance and unfortunately passed away.

The death was reported to the Coroner and statements were obtained from the staff involved. Dr B recalled verbally advising Ms D that she would need follow-up blood tests with her GP. He requested this instruction be included in the discharge letter. However, he neither prepared or reviewed the letter before it was sent. At the time, the hospital procedure was for nursing staff to complete all discharge documentation without medical sign-off.
 
The nurse involved stated that she had printed Ms D’s recent blood tests and attached them to the discharge summary. She also verbally confirmed with Ms D to follow up with her GP; this conversation was not documented.  
 
Dr R, the consultant in charge, had not been told about the abnormal results before discharge. He stated that, had he known, he would have advised urgent GP follow-up, within a few days.  

How Medical Protection assisted 

Dr B called the Medical Protection advice line after receiving the Coroner’s request for a statement. A medicolegal consultant assisted in preparing this, outlining his involvement and limited recollection of the conversation at discharge.

The inquest took place 18 months after Ms D’s death. Since Ms D’s niece was critical of the care received in hospital, Medical Protection arranged for Dr B to have legal representation at the inquest.

The cause of death was attributed to hypoxia secondary to a seizure related to hyponatraemia.

While the Coroner was not directly critical of Dr B, they commented that Ms D was not made sufficiently aware of the urgency of the follow up. A recommendation was issued for the hospital to review its discharge procedure, particularly the lack of guidance on how post-discharge investigations were arranged and communicated to patients and primary care. The hospital subsequently revised their discharge policy. Shortly after the inquest concluded, Dr B received notification that the Preliminary Proceedings Committee (PPC) of the Medical Council had received a complaint from Ms D’s niece. She was concerned Dr B had not emphasised the urgency of the blood tests and had not documented their discussion.

Dr B was assisted by Medical Protection in preparing a response, detailing the factual events, his reflections on the care provided to Ms D, and how his practice has changed. The PPC closed the case with no further action. Dr B was grateful to Medical Protection for the support provided throughout the two processes.

Learning points  

• Patients must receive clear and sufficient information about test results.

• Clinicians must explain abnormalities and allow for questions about follow-up plans.

• Timeframes for arranging GP blood tests must be explicit and clear.

• All patient discussions must be documented, and information communicated with relevant team members.

• Discharge letters to the GP should include sufficient detail on what is required, timescales, other relevant information about the patient and any concerns. 

• As discharge policies vary between hospitals, doctors should ensure they are familiar with the local policy.