Early discharge, deterioration and acute admissions: common themes in negligence claims

Acute medical teams frequently make decisions about whether patients require admission, can be discharged home or can continue receiving treatment through same-day emergency care. These decisions are often made in busy clinical environments, while a diagnosis is still evolving and often before important investigation results are available.

An adverse outcome following discharge does not necessarily mean that the care provided was negligent. However, claims may arise where relevant signs of deterioration were not recognised, the clinical reasoning behind discharge was unclear, important results were not followed up or the patient was not given adequate advice about when to seek further medical attention. 

This article considers some of the recurring issues that solicitors may encounter when reviewing claims involving early discharge, deterioration and transfers into same-day emergency care. 

As an acute medical consultant, work is based on the acute admissions unit.  

This means overseeing the first 72 hours of any adult medical admission. Turnaround is progressed rapidly by diagnosing, treating, stabilising and discharging patients as soon as possible. Those whom require a longer stay, will be identified early and transferred downstream to the relevant speciality and longer stay wards.  

Hospitals are becoming increasingly resource constrained, and as a result, the pressure to discharge patients sooner is increasing. This is not without risk.  

One modality to help to facilitate early discharge is same day emergency care (SDEC). A patient can be stepped down from inpatient care, to return for review and on-going treatment is handed over to a different team working in a (busy) ambulatory same day emergency care department. However there can be some common pitfalls during this transition, resulting in clinical negligence claims arising, often due to communication failures and errors made in clinical judgement.  

When reviewing these cases, the relevant question is not simply whether the patient deteriorated after discharge. Solicitors may need to consider whether the discharge decision was reasonable based on the information available at the time, whether appropriate monitoring and follow-up arrangements were made and whether responsibility for the patient’s continuing care was clearly transferred. 

The following themes do not automatically establish negligence. Instead, they identify areas in which the records, clinical reasoning and communication between teams may require closer examination.

Here are a summary of key themes to look out for: 

Communication between clinical teams 

Communication should be considered across the patient’s entire pathway rather than as an isolated exchange between two clinicians. A patient may move between the emergency department, the acute medical unit, SDEC, another specialty and primary care within a relatively short period. 

For solicitors, it may be important to establish what information was available to each team, whether any diagnostic uncertainty was communicated, who was responsible for outstanding investigations and whether the receiving clinician conducted an appropriate independent assessment rather than relying solely on the original working diagnosis. 

The typical communication points are listed below and these are potential areas of weakness if communication is poor.  

1. Between the emergency department referring into the SDEC team, especially with overnight referrals when direct communication has taken place.
2. Specialty ward or clinic teams referring a patient to SDEC for treatment or investigation, but without clear instructions or involvement by them for the SDEC team to take forward.  
3. GP referrals to the SDEC department with the wrong initial diagnosis or not recognising red flags from the history so that the handover is misleading to the accepting SDEC clinician and the patient is not treated appropriately.  
4. On the other side, poor communication between the clinicians themselves and the patient or their families may also be a source of problems. This is due to mismanaged expectations leading to poor understanding and patient experience.  

What solicitors may wish to consider 

Claims involving early discharge and acute medical care often require a detailed chronology. Relevant evidence may include observation and NEWS score trends, blood-test and imaging results, changes in the patient’s symptoms, responses to treatment, referral records, handover documentation, discharge summaries and any written or verbal safety-netting advice. 

It is also important to distinguish information that was reasonably available to the treating clinicians at the time from findings that became apparent only later. A subsequent diagnosis or deterioration does not, by itself, demonstrate that the original decision was unreasonable. 

An acute medicine expert may assist by considering whether the assessment, clinical reasoning, monitoring, escalation, discharge arrangements and follow-up were consistent with the standard expected in the circumstances. 

In Conclusion 

Early discharge and same-day emergency care can provide safe and effective alternatives to prolonged hospital admission. However, these pathways depend on clear clinical reasoning, effective communication, appropriate monitoring and reliable follow-up arrangements. 

Where one or more of these elements are absent, a patient may deteriorate without timely review or treatment. Examining the complete clinical pathway can help solicitors identify whether an adverse outcome arose despite reasonable care or whether there may have been an avoidable failure in the assessment, discharge or continuing management of the patient.