Managing post-discharge risk between hospital and general practice

Ms D, aged 79, underwent a total hip replacement performed by a consultant orthopaedic surgeon Dr R.  The operation itself was uneventful, but in the days that followed she experienced poor appetite and occasional vomiting. Routine postoperative blood tests demonstrated a low serum sodium level at 128, and a mildly elevated C-reactive protein. 

Despite these findings, Ms D’s overall condition gradually improved and Dr R felt she was well enough 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, Dr S, requesting an appointment for follow-up blood tests, as advised. Ms D told Dr S that she felt well. As no urgency had been conveyed by Dr B, the blood test appointment was scheduled for two weeks later. In the absence of specific details on the discharge summary, Dr S arranged for Ms D to have a check of her full blood count, her urea and electrolytes, and her liver function.  
 
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 hospital staff involved, as well as from the GP, Dr S. 

Dr S recalled that Ms D had not specified that the blood tests were urgent. On review of the discharge summary, there was no specific reference to the follow up bloods. However, it appeared that the nursing staff at the hospital had sent, with the discharge summary, a copy of the patient’s last hospital blood test, documenting a serum sodium level of 128. This test result appeared to have been filed by the practice administrative team, and only the discharge summary had been flagged to Dr S at the time of Ms D’s discharge.  
Dr S stated that, had they been aware of the recent hospital blood results, they would have arranged blood tests within two to three days.  

How Medical Protection assisted

Dr S called the Medical Protection advice line after receiving the Coroner’s request for a statement. A medicolegal consultant assisted in preparing this, outlining their involvement in arranging follow up bloods, as well as their limited recollection of what Ms D had told them. 

The inquest took place 18 months after Ms D’s death. Since Ms D’s niece was critical of both the hospital and GP care received, Medical Protection arranged for Dr S 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 S, they commented that Ms D had not been sufficiently aware of the urgency of the follow up. As well as making several recommendations to the hospital, the Coroner highlighted the importance of GPs being able to access test results after a patient’s discharge from hospital. The GP practice subsequently amended their policy for dealing with discharge summaries, ensuring that all attachments, as well as the actual summaries, would be brought to the attention of GPs. 

Shortly after the inquest concluded, Dr S 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 S had not taken steps to ascertain the urgency of the requested blood tests. 

Dr S was assisted by Medical Protection in preparing a response, detailing the factual events, their reflections on the care provided to Ms D, and how their practice had changed. The PPC closed the case with no further action. Dr S 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, ideally in writing. 

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

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

• Timeframes for arranging GP blood tests must be explicit and clear. If GPs are not clear on the timeframe and the nature of the blood tests required, they should contact the discharging hospital staff to clarify the request. 

• GP practices should have a robust policy regarding the management of hospital discharge correspondence, including ensuring that all relevant documentation is brought to the attention of the relevant GP. 

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