Transitional Care and Arrival at UEA
During Averil's time in the S3 Unit at Addenbrooke's, her weight increased from 30.4kg to 45.2kg.
This was below a healthy range weight and below Averil's target weight but she was due to start University in September. Even though she was still considered a high risk patient, following an appraisal from Dr. Shapleske and a meeting with Averil's mother, Averil was discharged in August 2012.
Although it was noted Averil was anxious about her discharge, a number of arrangements were put in place to ensure her recovery continued as she was due to start at University in the September.
These arrangements were as follows:
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A referral to NCEDS, Cambridge and Peterborough Foundation Trust Hospital- her follow up with the team and the appointment of her care coordinator was scheduled for when she started University in September
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That she would register with a GP at UEAMC as soon as she arrived at University
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Until then she would continue her work and recovery with her current Doctor
The discharge summary also included the following instructions for her assigned GP at UEA Medical Centre:
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'Please check Averil's physical health every week (weight, BP, heart rate and level of physical strength - squat test). This can be done by any nurse. Please monitor her bloods every 2-3 months, including U&Es, bicarbonate, LFTs, bone profile, muscle CK, Magnesium and Phosphate.'
Contrary to relevant guidelines, further consideration was not given to the fact that Averil was being discharged from one service to another. Along with the fact she was moving from her family home to University where she would be
completely independent.
This put Averil at further risk of relapse and this failure to account for them affected the suitability of the treatment that would be provided by Averil in the future.
Averil moved to Norwich on the 23rd September 2012, and registered with the GP on the 29th September, booking her first appointment for the 5th October. This first appointment was a new patient health check with the UEAMC's healthcare assistant. Averil's weight, BMI and blood pressure were recorded.
Although a referral was made to NCEDS in August when Averil was discharged from the S3 Unit, there was a significant delay in the referral process which meant that Averil was not seen by a specialist for nearly 8 weeks. During this time transitional care was essential.
During this time Averil's care coordinator was to provide monitoring and support. The latter stages of the transitional care consisted of phone calls alone, with no record of discussions related to weight or other essential parameters, which should have been recorded by Averil's GP or discussed by the care coordinator.
As a result of this arrangement,
no handover meeting took place but transfer of responsibility was achieved by a telephone phone call.
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This meant that Averil's condition was not properly communicated to those taking over her care.