Summary: There was some poor recording and communication by the care provider, for which it has apologised. However, there is insufficient evidence to say the care provider was at fault in being unable to readmit the late Mr X to the hospice on 8 April.

The complaint

1. Mrs A (as I shall call her) complains on behalf of her late brother Mr X about the care and treatment provided to him in March and April 2022. In particular she complains about his discharge on 11 March and the care provider’s refusal to readmit him on 8 April, shortly before he died.

Back to top

The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4)

Back to top

What I have and have not investigated

4. I have investigated the complaint as set out above It is not the role of the Local Government and Social Care Ombudsman to investigate the actions of clinical staff.

Back to top

How I considered this complaint

5. I considered all the information provided by the care provider and by Mrs A. I spoke to Mrs A. Both Mrs A and the care provider had the opportunity to comment on an earlier draft of this statement and I considered their comments before I reached a final decision.

Back to top

What I found

Relevant law and guidance

6. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
7. Regulation 17 says that care providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.
8. Hospices provide free nursing and medical care for anyone with a terminal illness or life-limiting condition. There are specific criteria for admission. Spaces are limited by hospice capacity including staff levels, skills mix, patient acuity, bed numbers and community caseload numbers.
9. The Wheatfields Hospice publishes its terms for accepting referrals on its website. In respect of in-patient referrals, it says, “Referrals are considered at a meeting held each weekday morning. Urgent referrals (i.e. requests for admission that day) for patients in their own homes are considered on an individual basis based on a variety of factors including patient needs and availability of beds.”

What happened

10. The late Mr X had a period of care in the hospice in early 2022.

Events 10 and 11 March 2022

11. Mrs A says on 10 March she visited in the morning as that date had been flagged as a possible discharge day. She says Mr X was in some distress as he said he had been asking to have a bath from early morning, but staff told him there was no-one to help. She says some hours later a nurse told him he could have a bath without assistance. He asked her to show him how to use the hoist and said he would call if he needed help. She says she waited in his room and it was some time later that he wheeled himself back, dressed only in a robe, and visibly distressed. He said he had been shouting for help and no-one came. Mrs A points out that by this time her brother had pressure sores on his feet and about 8 litres of ascites in his stomach.
12. Mrs A says she suggested her brother have a sleep and she started to clear the glasses and plates on the tray over his bed. She says one of the glasses broke into small pieces around Mr X’s feet and on his bed, and she told him not to move until she could clear it up. She says she asked for utensils to clear the glass but it was some time before this was provided.
13. Mrs A says she asked for Mr X’s medical notes from the hospice after he died. She says she was horrified to read the notes recorded her brother had “refused assistance” to have a bath and placed himself in and out of the bath independently. The notes went on to say he had “expressed some behaviours which were difficult to manage”. They said he had knocked over and smashed a glass in his room, and had been incontinent of faeces in the bath and had not told anyone.
14. Mrs A says when the doctor saw Mr X that day, she said he was not well enough to be discharged and would be assessed over the next 24 hours. She says however within a few minutes of the doctor leaving, a discharge coordinator arrived with paperwork to complete. She says both she and Mr X were shocked and Mr X asked if he could stay until the next afternoon. Mrs A says the discharge coordinator said they needed the bed and would rather he left in the morning.
15. Mrs A says the events of 11 March were very distressing as her brother was in a worse condition than when he had been admitted to the hospice and knew he was deteriorating. She says the physiotherapy assessment notes suggest it took him over 30 minutes to climb three steps. His stomach was distended with fluid but he was just offered a grabber to enable him to pull up his socks as he could not lean over far enough. She says his mental health and his physical health was such that he should not have been discharged.
16. The hospice says a referral was made the community hub on 10 March (as the discharge coordinator did not work on 11 March) and the District Nursing staff also accessed the electronic system following Mr X’s discharge.

Events leading up to Mr X’s death

17. Mrs A says her brother spoke to his consultant on 22 March and said he was low in mood and hadn’t heard recently from the clinical psychologist. The consultant said she would chase this up but Mrs A says the psychologist should have been in contact before then.
18. On 1 April the consultant visited Mr X at home. Mrs A was also present. The consultant recorded “Family feel like they don’t know who's role is what and when things will happen”. She told them “can use hospice for signposting via CNSs” (the clinical nurse specialist service).
19. On (Friday) 8 April Mr X had a phone call with the palliative nurse specialist. The notes record Mr X was “very distressed, needing to talk, asking about admission”. He said he wanted to “end it all” but the notes record “as we talked he sounded brighter and felt we made a plan”. Mrs A says her brother asked to go into the hospice to have a bath as this helped to relieve his pain: the nursing notes record he “understands he can't come in just for that” and implied it was for personal care rather than pain relief. The notes record Mr X was told someone would contact him again after the weekend.
20. Mrs A telephoned the hospice later that day and asked for a doctor to call Mr X as she was so concerned about him. She says it was several hours later when a doctor rang Mr X. The doctor noted Mr X said he had been “low” that morning but was not so distressed now. She noted “Ongoing care- we discussed the plans for the next few days. (Mr X) now aware what medication he should be taking, and states he has it all available. He feels ok now, and feels reassured that (a nurse) will ring him on Monday, but understands can ring us before then. Discussed possible admission to Wheatfields at some stage if things are deteriorating, but it does not sound like he needs admission currently. (Mr X) is accepting of this, but wanted to be clear that his preferred place of death is Wheatfields Hospice when we feel he is at that stage.”
21. The doctor also telephoned Mrs A. Mrs A says the call was cut off and the doctor then left a voicemail saying they could be in touch on Monday if Mr X felt no better.
22. Mr X died on 12 April in hospital after he was referred there by the District Nurse as he was in so much pain. Mrs A says she believes the hospital tried to refer him back into the hospice on 11 April but did not receive a response.

The complaint

23. In October 2022 Mrs A complained to the hospice about the way it had treated her brother on and around the days he was discharged, its false recording of the incidents in the bath and with the broken glass, its failure to support him when he requested to be admitted for a bath to alleviate his pain, and then its refusal to admit him (despite his indication that he was suicidal) shortly before he died. She said he was not able to die in the hospice as he wanted.
24. The service director replied. He apologised that Mrs A felt her brother had been made to feel unwelcome on the day he was discharged. He apologised for the poor communication when Mr X requested a bath that day but said the view of staff was that Mr X had had the capacity to make the decision to take a bath despite staff not being available to assist. He acknowledged that there was poor recording about the way in which the glass had been smashed and said staff had been reminded of the need for accuracy.
25. The service director said the physiotherapist had clarified that it had not taken Mr X 30 minutes to climb three steps. He said the grabber had been offered as part of the discharge plan.
26. In respect of the phone calls on 8 April, the service director said, “As part of our investigation we have also checked whether an admission to Wheatfields hospice could have been facilitated at this point. Unfortunately, I can confirm it appears likely this may not have been possible as we had already reached the maximum number of planned admissions that day.”
27. Mrs A replied to the complaint response. In particular she asked whether or not the hospice had reached maximum capacity on 8 April and if so, why that had not been said during one of the many phone calls which had been made that day.
28. A senior service director responded to Mrs A and advised a complaint to the Ombudsman if she remained dissatisfied. Mrs A says she felt the senior service director responded to her with “insincere platitudes”. Mrs A complained to the Health Service Ombudsman (who referred the matter to us as it is outside their jurisdiction.)
29. The care provider has provided the relevant clinical notes about the complaint.
30. The care provider does not have separate notes for the multidisciplinary meeting it says would have taken place on the morning of discharge. The chief nursing officer says, “this would include any issues about readiness for discharge”.
31. In respect of the capacity of the hospice on 8 April, the chief nursing officer says although not all beds were full, it was at capacity having already accepted three admissions. She says capacity is dependent on staffing levels, skills mix, patient dependency, patients’ safety, patients already booked for admission, urgent requests for admission and transport availability. She also points to part of the telephone conversation Mr X had on 8 April with the hospice doctor, where he is recorded as saying he was not sure whether he wanted admitting to the hospice at the moment as he was enjoying being at home with his family.

Analysis

32. The care provider acknowledges there was misleading recording about the smashed glass in Mr X’s room. There was also nuanced recording about his incontinence in the bath which implied deliberately poor behaviour on his part. Those were faults for which the hospice has apologised.
33. The telephone notes from 8 April together with Mrs A’s records show the considerable distress being suffered by Mr X. The way in which he died was shocking for his family and has left lasting difficult memories. But there is no evidence to show that there was space at the hospice to which he should have been admitted and which he was, for some reason, denied.

Back to top

Final decision

34. I have completed this investigation on the basis that the care provider has already apologised for some poor communication and the shortcomings in its recordings and there is no other evidence of fault on its part which caused injustice to Mr X.

Investigator’s decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman