SENTENCIA DEL TRIBUNAL CONSTITUCIONAL ESPAÑOL 198/2012

Seventy-three-year-old Ralph had a stroke in September 2012. It happened at his home, a small rural cottage 30 miles from Farnchester, where he lived with his daughter and an elderly friend. Ralph was assessed by a paramedic and transported by ambulance to Farnchester emergency department. He was assessed by the medical team and transferred to the stroke unit. Dr White, the specialist stroke consultant, assessed Ralph’s physical condition and requested further diagnostic tests. He enquired about his history and reviewed his medical records, including previous transient ischaemic attacks (TIAs) and strokes. Dr White asked Ralph about changes in his general health and medicines use since his last stroke, and made an initial assessment to determine the extent of the stroke, the likely pathway he was to follow and ongoing care needs. These were recorded in his medical records together with instructions to stabilise and monitor the patient overnight. Ralph was clerked on to the stroke unit by a ward nurse where additional physical, personal and domestic information was recorded in a shared hospital record.

The following morning Ralph’s status was briefly reviewed as a part of the morning board round. Like all patients on the unit, Ralph’s basic details were recorded and reviewed on a wall-mounted whiteboard in the reception area, which listed his general condition, any instructions for observation and any outstanding tasks in relation to his care. The lead ward nurse, a therapist representative and a HCA quickly reviewed this information; the therapist noted Ralph’s admission to the unit and made a note to obtain any pre-existing care records and to visit him later in the day.

Later that morning, Ralph was reviewed as a part of the daily ward round. This was led by Dr White and Ralph’s ward nurse, together with four junior doctors and an OT and PT designated to that ward area. These clinicians congregated around his bedside to review his care progression; the results obtained from diagnostic tests; his speech, mobility and cognition; and options for his discharge (‘what shall we do with you next?’). Dr White verbally asked that his OT (Mandy) and PT (Theresa) commence rehabilitation and mobility exercises, and clarify his domestic circumstances in preparation for discharge planning. Dr White also requested that Ralph’s medication be reviewed by the stroke unit pharmacist.

Later that day, Ralph commenced intensive rehabilitation on the ward with Mandy and Theresa. Theresa focused more on his physical mobility, standing and walking, whereas Mandy asked questions about his home environment, activities of daily living and general well-being. The three-way interaction helped established a more nuanced understanding of his expected needs and recovery. The close and personal interaction also enabled Ralph to express his anxieties about his general health. The therapists used this opportunity to reassure Ralph about his recovery. The OT and PT spent over 30 minutes with Ralph and recorded a summary of their activities in the shared patient record, including a plan of action for future mobilisation. This also included a note to discuss his home circumstances with his family, either by

telephone or during a hospital visit. On the same day, Ralph was also visited by the stroke unit pharmacist, following a request from the ward nurse. The pharmacist reviewed his medicines and endorsed the decision of Dr White to reduce his medication load.

At the end of the day shift, another board round was conducted to record general changes on the ward and to identify any outstanding tasks. This was attended by the junior doctors, nurses, OT and PT leads, HCAs and SaLTs. At this meeting, Mandy asked the evening OT (Sally) to contact Ralph’s family members either by telephone or in person. As they did not visit Ralph on this day, Sally contacted Ralph’s daughter by telephone to explain his condition and arrange a meeting the following day.

On the second day, Ralph’s daughter and Mandy met briefly before she visited him on the ward. Meeting without Ralph seemed to provide an opportunity for his daughter to raise concerns that she might not be able to raise in front of her father. It also enabled Mandy to gather a more detailed understanding of Ralph’s home environment. Following this, Ralph met with both his daughter and OT at his bedside to review similar issues and to consider his preferred domestic arrangements.

For the next 3 days, Ralph’s care generally followed the same pattern of being reviewed and assessed through board rounds and ward rounds, and having regular therapeutic input. On day 4, Ralph’s case was reviewed at the weekly MDT. This was led by Dr White and involved input from the nurse in charge, representatives from the therapist team, the specialist community stroke nurse and a stroke association representative. Ralph’s case was introduced by Dr White, who summarised his diagnosis and care plan, followed by the OT and PT leads, who gave a summary of their involvement using the shared record. The ward nurse also reviewed his progress and suggested rapid discharge home, given that he seemed to be responding well to recovery and that he was generally anxious about staying in hospital. Through the meeting, the decision was made to discharge Ralph the following day, and to consider his transport arrangements, medicines and follow-up care. These decisions were recorded in both Ralph’s medical notes and the shared care record. No direct instructions were given to any one individual or group, but the different professionals involved made separate notes for actions to be followed.

Later that day, Ralph’s progress was again reviewed as a part of the evening board round, where the nurse in charge allocated relevant tasks for his forthcoming discharge, including arrangements for his medicines and transportation. Following this review, one junior doctor consulted Ralph’s medical records and made arrangements for his TTOs, using the hospital’s electronic prescribing system. Later the same day, one of the OTs (Sally) met with Ralph and his family to review his discharge arrangements. It was decided that a hospital taxi would be more convenient to transport him back to his rural home rather than waiting for the ambulance service. No other arrangements were made with the community health-care provider and no referrals were made with social care providers because the OT believed he was not eligible for support. On the morning of his fifth day in hospital Ralph was discharged home. This commenced with the daily board round, where the final tasks for his discharge were allocated. The taxi was booked in the morning by the ward receptionist, who also advised Ralph that he would have his follow-up appointment sent by post. Ralph’s medicines were ready for him on departure after being delivered to the unit by the 24-hour pharmacist service. Before Ralph was discharged home, the junior doctor told him that he still needed a heart scan but that this could not be arranged until the next morning. As such, he could either delay the discharge or return to the hospital the next day. Ralph decided to return the next day. The junior doctor also informed Ralph that a discharge letter would be sent to his GP by Dr White within the week. After arriving home, Ralph was extremely tired and later felt that the hospital therapy‘was too much exercise’for him. His daughter looked after him that evening and reported that Ralph experienced a fall when using his toilet on his own. There were no evident physical consequences from this fall, but he later felt it was too difficult for him to get upstairs. The next morning, Ralph and his daughter returned to the hospital for his heart scan; he was told that he had a slight murmur but nothing significant. Later in the afternoon he visited his GP to review his care, and the GP arranged a commode to be delivered later that day after Ralph explained his difficulties in getting around the house.

The following morning Ralph restroked. The paramedic service attended to him at home before an ambulance transported him back to hospital. Upon readmission, he was told by Dr White that it was

an extension of his previous stroke, and he was admitted for a further 4 days. This time Ralph had more severe physical and speech impairments from his stroke and required additional therapist input. Ralph believed that he had had another stroke because he was given too much extensive therapy in hospital and because his medicines had been changed. Meeting with Ralph at his home 4 weeks later, he reported that he had made some recovery from his stroke, including improved mobility. However, he had received no support from the community stroke nurse because she did not cover his area. Ralph managed to obtain a wheelchair, walking aids and hand rails around his home, but he said that these were provided by a community specialist heart nurse who was looking after his elderly lodger, and were not strictly for his use. As his daughter explained, they lived outside of the catchment area for the community stroke service so were lucky to benefit from these other services. His daughter also thought that the GP was very supportive, making regular home visits to check up on him, and the local pharmacist had reviewed his medicines to help him follow his prescription. She also said that he relied upon his neighbours to help transport him to subsequent hospital appointments.

Appendix 4

Extracts of data on knowledge

sharing and discharge planning

Tabulated