Summary: Mrs O complained about arrangements for her late mother’s discharge from hospital to a care home during the COVID-19 pandemic. She said her mother was too unwell to be discharged and should have stayed in hospital. Mrs O also complained about her mother’s care at the care home. Mrs W’s health deteriorated within a few days of leaving hospital and she died. We did not find evidence of fault by the organisations.

The complaint

1. Mrs O complains about the care of her late mother Mrs W in January and February 2021, during the COVID-19 pandemic. She complains about her mother’s care in hospital (part of Bedfordshire Hospitals NHS Foundation Trust). She also complains about the decision to discharge her mother to Moorland Gardens Care Home (a joint process involving Bedfordshire Hospitals NHS Foundation Trust, NHS East London NHS Foundation Trust and Central Bedfordshire Council), and about her care at Moorland Gardens (under Central Bedfordshire Council). In particular, she complains that:
• Her mother was not well enough to be discharged, and should have stayed in hospital to receive End of Life Care
• The hospital mistakenly said her mother was diabetic, and passed this information on to the care home which affected her care there
• The care home could not meet her mother’s needs and she should not have been placed there
• The care home did not provide satisfactory care for her mother, and did not seek medical help quickly enough when her condition declined
• When her mother was readmitted to hospital and was dying, the Trust would only allow one visitor at a time (under COVID-19 restrictions) despite other patients being allowed more
2. Mrs O said her mother went through unnecessary pain and suffering at the end of her life due to these failings in her care. Mrs O said she has not been able to move on from her mother’s death due to the circumstances, and has developed Post Traumatic Stress Disorder, anxiety and other mental health problems.
3. Mrs O said she wanted an independent investigation into her mother’s care, to understand what happened and what went wrong. She also wants a financial remedy to recognise what happened to her mother and the impact it has had on her.

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The Ombudsmen’s role and powers

4. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, a single team has considered these complaints acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
5. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
6. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship. (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended) If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
7. When considering complaints, if there is a conflict of evidence we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
8. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)
9. This complaint involves events that took place during the COVID-19 pandemic. The Government introduced new and frequently updated rules and guidance during this time. We can consider whether the organisations followed the relevant legislation and guidance, and whether Councils followed our published “Good Administrative Practice during the response to COVID-19”.

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How I considered this complaint

10. I have considered information Mrs O provided in writing and by phone. I have considered written information from the Council, both NHS Trusts and the Home, as well as relevant law and guidance. I have also taken independent clinical advice from a consultant physician.
11. Mrs O and the organisations had the opportunity to comment on a draft of this decision. I took all comments into account before making a final decision.
12. For clarity, I will refer to Bedfordshire Hospitals NHS Foundation Trust as ‘the acute Trust’ and NHS East London NHS Foundation Trust as ‘the ELFT Trust’.

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What I found

Background

13. Mrs W, aged 91, went into hospital on 8 January 2021 after falling outside during the night. She had hypothermia. Mrs W had several pre-existing health conditions including dementia and atrial fibrillation (fast heart rate). She lived in her own home with carers coming in four times a day.
14. Once in hospital Mrs W was diagnosed with a chest infection and received treatment including antibiotics. She was also seen by the cardiology team because of her atrial fibrillation. On 18 January the medical team decided Mrs W was stable enough to be discharged from hospital. The hospital started to arrange for her discharge including looking at the care package she would need.
15. On 20 January Mrs W tested positive for COVID-19. Plans for her discharge had to be changed as she needed to go to a “designated setting” - a residential placement for people being discharged from hospital with a positive COVID‑19 result and who needed 24-hour care.
16. The hospital contacted Bedfordshire Community Health Services (BCHS, part of the ELFT Trust) and asked it to arrange a discharge placement for Mrs W. BCHS made a referral to Moorland Gardens as this was the “designated setting” care home for COVID-positive patients in the area. BCHS said this was the only option for Mrs W as other care homes would not accept COVID-positive patients then.
17. Moorland Gardens reviewed the referral for Mrs W, liaised with the hospital and confirmed it could meet Mrs W’s needs. BCHS then contacted the hospital and asked it to arrange for Mrs W’s discharge to Moorland Gardens.
18. Meanwhile, the hospital reviewed Mrs W’s clinical condition each day, including taking regular blood tests, monitoring her temperature, and taking some chest x-rays. On 26 January Mrs W had a high temperature. The hospital gave her antibiotics and paracetamol. Staff reviewed Mrs W again on 27 and 28 January, noting on 27 January that her chest X-ray showed “BL (bilateral) patchy opacities ?covid-related”. On 28 January staff noted Mrs W’s temperature had returned to normal, and blood tests had not shown any bacterial infection.
19. Medical staff noted Mrs W had ‘chest crackles’, which can suggest mucus or fluid in the base of the lungs. They documented that Mrs W had been on antibiotics, her infection was improving, and that she was medically fit to be discharged. Mrs W was discharged to Moorland Gardens in the afternoon on 28 January.
20. According to the records from Moorland Gardens the first few days of Mrs W’s stay there were relatively stable. However, on the morning of 1 February Mrs W’s condition declined. The Home called an ambulance and Mrs W went back to hospital. The hospital noted Mrs W was short of breath, was generally unwell, was not drinking much fluid, and had a high heart-rate.
21. The hospital carried out investigations including blood tests and chest X-rays. Staff felt the chest X-rays showed that Mrs W had COVID-pneumonitis (inflammation of the lung tissue). The hospital contacted Mrs O and told her that her mother was unwell and may not survive. Mrs O was very upset and said she felt her mother had not been well and should not have been discharged from hospital. The hospital said Mrs W’s chest X-ray on 27 January had been clear.
22. Mrs W died in hospital on the morning of 2 February 2021. The primary cause of her death was COVID-19 pneumonitis. The cause of death also noted her frailty due to old age, dementia, and atrial fibrillation.
23. Mrs O complained about her mother’s care. She felt her mother had not been fit to be discharged from hospital and should have stayed in hospital to receive End of Life Care. Mrs O was also concerned about her mother’s decline at the Home, whether the Home was suitable for her needs, and whether it called for medical attention quickly enough when her condition declined. Mrs O complained about COVID-19 patient visiting arrangements at the hospital when her mother was dying.

Analysis

Discharge from hospital

24. The acute Trust said Mrs W was frail but stable enough to be discharged to a 24‑hour care setting. It explained that being medically fit for discharge does not mean a patient is fully recovered, rather that they no longer need in-patient hospital care. The acute Trust said the doctors looking after Mrs W felt her discharge was appropriate and that she was likely to improve after discharge. It said staff could not have foreseen that a few days after discharge she would deteriorate so significantly and need to be re-admitted to hospital.
25. The Home said Mrs W was stable and was not thought to be nearing the end of her life when she was discharged to its care. It said she deteriorated significantly a few days after being discharged and became extremely ill.
26. I have carefully considered all the evidence, including Mrs O’s accounts, and the records from the Council, Moorland Gardens and the two NHS Trusts. I have compared and cross-referenced the evidence from different sources to consider the conflicting accounts of events. Having done so, I have not found fault in the decision to discharge Mrs W from hospital on 28 January 2021.

Law and guidance

27. The relevant guidance in place at the time was:
• ‘Hospital discharge service: policy and operating model’ (Department of Health and Social Care, 16 September 2020)
• ‘Admission and Care of Residents in a Care Home during COVID-19’ (Department of Health and Social Care, Care Quality Commission and UK Health Security Agency, 24 December 2020)
• ‘Discharge into care homes: designated settings’ (Department of Health and Social Care, Care Quality Commission, NHS England and UK Health Security Agency, 13 January 2021)
• ‘Admission Policy’ (Bondcare, 6 January 2021)
28. The ‘Hospital discharge service policy’ set out how health and care systems could ensure people were discharged safely from hospital to the most appropriate place, and continued to receive the care and support they needed after they left hospital. The policy said hospitals must discharge people who no longer met the criteria to be in hospital as soon as it was clinically safe to do so. This was because of the importance of moving people out of hospital and freeing up beds as quickly as possible during the COVID-19 pandemic.
29. The ‘Hospital discharge service policy’ makes it clear that discharge from hospital should take place “in a safe and timely manner”, as soon as it is “clinically safe” to do so, and once any ongoing care and support needed has been organised.
30. Moorland Gardens was a “designated setting” - a residential placement for people being discharged from hospital who had a positive COVID-19 result.
31. The ‘Designated settings guidance’ said people being discharged from hospital to a care home who were COVID-19 positive would be discharged to a designated setting (care home) to complete the recommended 14-day isolation period.
32. I asked our clinical adviser to comment on the decision to discharge Mrs W to Moorland Gardens on 28 January 2021 and on the complaint responses from the organisations. Have considered the clinical advice, and the evidence from Mrs O, the Council, the two NHS Trusts and the Home, it is my view there was no fault in the decision to discharge Mrs W.

What happened

33. After testing positive for COVID-19 on 19 January 2021, Mrs W was relatively stable and considered medically fit for discharge until the early hours of 26 January when she developed a high temperature of 38.3C and her blood pressure was raised at 181/81. The hospital started antibiotics and gave pain relief.
34. Mrs W still had a high temperature early on 27 January (38.3C at 03:35am). A discharge officer noted Mrs W was due to be discharged the next day and said this decision would be reviewed once the ward team had seen Mrs W that day. The clinical notes from the ward round later on 27 January said blood test results were due, and “if no more temps, aim home tomorrow”.
35. On 28 January Mrs W was reviewed by a doctor at 11:20. The doctor felt Mrs W’s infection was improving and her temperature had settled. The doctor also noted Mrs W had a mild acute kidney injury (‘AKI’ - a sudden and recent decline in kidney function, often due to dehydration or decreased blood flow. Mild acute kidney injury is often treated with fluids, either orally or through a drip). The doctor prescribed two bags of fluid to be given through a drip and said Mrs W would be medically fit for discharge ‘tomorrow’ (i.e. 29 January).
36. Staff took clinical observations of Mrs W on 28 January at 05:37, 09:55 and 13:41, including oxygen saturation, blood pressure, pulse and temperature. These were all within normal range. Nursing staff noted Mrs W was not complaining of pain, could communicate well, did not need an oxygen mask, was eating and drinking well, and was comfortable. Our clinical adviser also said the X-ray images from 27 January did not give cause for concern about Mrs W’s medical fitness to be discharged.
37. It is clear from the hospital notes that shortly after the medical review on the morning of 28 January, arrangements for Mrs W’s discharge started to progress. By mid afternoon her discharge medications were ready, her discharge letter had been reviewed and patient transport had been activated. Mrs W was discharged late afternoon to Moorland Gardens.
38. It is not clear from the medical records whether a doctor reviewed Mrs W again before she was discharged. The last documented medical review was at 11:20, when the doctor felt Mrs W was improving and would be medically fit for discharge the next day. It is also not clear from the medical records whether Mrs W had the fluids the doctor had prescribed as the records are incomplete. I asked the Trust about this during my investigation.
39. The Trust said it acknowledged the intravenous fluid records and fluid balance charts were not fully completed for 28 January. The Trust also acknowledged the discharge letter was not updated with Mrs W’s positive COVID status. It has acknowledged these failures in record keeping and apologised.
40. The Trust also said it was not clear from the medical notes whether Mrs W was medically reviewed again after 11:20 on 28 January, before being discharged to Moorland Gardens. The Trust said it was common practice for patients waiting for a ‘step-down bed’ to be given little notice of bed availability, and medical staff are then asked whether the patient is suitable to transfer from hospital to a ‘step-down bed’. The Trust said it was not necessarily the case that Mrs W would only be fit for discharge after having intravenous fluids. It said encouraging oral intake of fluids would have been enough. This could have been done by the Home, rather than as a hospital in-patient.

What I found

41. It is difficult to establish a precise sequence of events for the afternoon of 28 January, because of some gaps in record keeping I have outlined above. However, on balance, I have concluded it was appropriate for Mrs W to be discharged to Moorland Gardens that day. Mrs W was still unwell and needed ongoing care and support. However, this did not have to be provided in an acute hospital setting. It is not appropriate to keep patients in an acute hospital setting purely because there is a risk they might deteriorate. Also, during the COVID-19 pandemic, national guidance said hospitals must discharge people as soon as it was clinically safe to do so, and once any ongoing care and support needed had been organised.
42. It is important to note that Mrs W was being discharged to a care home for ongoing 24hr care and support, as opposed to being discharged to her own home with carers coming in intermittently. The hospital provided handover information to the care home, and the care home had a Care Plan in place for Mrs W including meeting her needs arising from COVID-19. The Care Plan included the need for regular observations of her temperature, pulse and oxygen levels, and to observe her for signs of breathless and tightness of the chest, which could indicate pneumonia. It also outlined the need to look out for emergency warning signs that could relate to severe illness arising from COVID‑19 infection.
43. Our clinical adviser explained the decision to discharge Mrs W on 28 January is unlikely to have made any difference to what then happened. There was no treatment available then that would alter the progress of COVID‑19 (as set out in guidance from the National Institute for Health and Care Excellence ‘COVID‑19 rapid guideline: critical care in adults’, updated September 2020). Staying in hospital is unlikely to have prevented Mrs W’s later deterioration or her death.
44. The natural progression of COVID-19 in some people was a sudden deterioration a week or two after getting the infection. In Mrs W’s case, the evidence suggests she was stabilising before discharge to Moorland Gardens, and then had a sudden deterioration a few days later on 1 February 2021. She went back into hospital ‘in extremis’ (very severely ill) with COVID-pneumonitis (significant inflammation and damage in the lungs). Our clinical adviser said this was a pattern seen with many elderly patients during the second wave of the COVID-19 pandemic.
45. Taking everything into account, I have not seen fault in the decision to discharge Mrs W to Moorland Gardens on 28 January for ongoing care and support. The organisations’ actions were appropriate and in line with the relevant policies and guidance in place.
46. I have seen some fault in the acute Trust’s record keeping, but I do not consider this had any negative impact on Mrs W or her care. As outlined above, the decision to discharge Mrs W on 28 January is unlikely to have made a difference to the outcome in terms of her sudden deterioration and sad death a few days later.
47. The Trust has confirmed it has taken action to address the issues about record keeping. It said that due to staffing pressures because of the COVID-19 pandemic, its documentation audits were not as robust at that point in time. However, the Trust has confirmed that wards are now carrying out documentation audits across the Trust, which are reviewed by the Ward Manager and Matron. Any areas of concern are escalated to the wider ward teams for learning, and results are reported into governance meetings. I consider this action is appropriate to address the failings in record keeping here.

Deterioration, and re-admission to hospital

48. Mrs O complained the Home could not meet her mother’s needs and she should not have been placed there. She also said the Home did not provide adequate care for her mother and did not act quickly enough when she deteriorated on 1 February.
49. The evidence from the acute Trust, the ELFT Trust and Moorland Gardens shows that Moorland Gardens received a Single Assessment Form from the acute Trust which set out Mrs W’s condition and care needs. Moorland Gardens carried out an assessment (remotely) and confirmed it could meet Mrs W’s care needs. Moorland Gardens was the designated setting for COVID-positive patients being discharged from hospital in that area.
50. I have not seen anything to suggest Moorland Gardens was not an appropriate ‘step-down’ placement for Mrs W. Also, the hospital provided detailed handover information, and the Home had a Care Plan in place for Mrs W including meeting her needs arising from COVID-19. The Care Plan included the need for regular observations of her temperature, pulse and oxygen levels, and to observe her for signs of breathless and tightness of the chest, which could indicate pneumonia. It also outlined the need to look out for emergency warning signs that could relate to severe illness arising from COVID‑19 infection.
51. I have reviewed the Home’s records and can see that staff carried out regular observations and documented them. Staff also documented that Mrs W was taking a reasonable amount of fluid intake. Mrs W had a sudden decline on the morning of 1 February. Staff noted she had a raised pulse at around 9:30 and her oxygen saturation levels were low. The Home called an ambulance and it arrived within ten minutes. Mrs W was then taken to hospital, where she was noted to be frail, breathless, unwell and confused.
52. After being re-admitted to hospital, Mrs W continued to deteriorate. She sadly died on the morning of 2 February.
53. As I have outlined earlier, Mrs W was frail and she was at considerable risk of severe COVID-19 outcomes including death. She was re-admitted to hospital promptly after deteriorating at Moorland Gardens on 1 February. I have not seen any evidence of poor care at Moorland Gardens or a delay in responding to her deterioration and calling an ambulance.

Information about diabetes

54. Mrs O said the hospital wrongly told the Home her mother had diabetes, and this impacted on her care and her diet there. I have reviewed the records to look at this issue.
55. The Hospital Discharge Notification document said ‘no special diet required’ However, Mrs W’s Care Plan at Moorland Gardens said ‘she is on normal diet and diabetic’. The care notes for 28 January also say ‘diabetic menu but normal diet’. I have not seen any other references to Mrs W being diabetic, in either the acute Trust or Moorland Gardens records.
56. I can appreciate Mrs O’s concern there was some mention of her mother being diabetic in some of the Home’s records, as this was not correct. However, I have not seen any evidence that this negatively impacted on Mrs W’s care or her diet. In most places, the Home’s records refer to Mrs W being given a normal diet. Some of the meal entries include reference to foods like omelette, porridge, orange juice, mashed potato and chocolate cake.
57. Mrs W’s care home records should not have referred to her as having diabetes as this was wrong. This was fault. However, I cannot see it had any negative impact on Mrs W. I have not considered this matter further.

Hospital visiting arrangements

58. Mrs O said when her mother was readmitted to hospital and was dying, the acute Trust would only allow one visitor at a time (under COVID-19 restrictions) despite other patients being allowed more.
59. The acute Trust said when Mrs W was re-admitted on 1 February she was extremely ill. It said her family was allowed to sit with her one at a time, and that patients at the end of their life were allowed to have visitors. The acute Trust said it appreciated that COVID restrictions on visiting were difficult for patients and their families. It said each area had its own visiting restrictions, led by the Trust’s Infection Control Team. It said it apologised for the upset caused because of the necessary restrictions that were in place.
60. In January 2021, England was in a national lockdown following a rapid rise of COVID-19 infections and hospital admissions. Many NHS Trusts had decided to suspend visiting in hospital, except in very limited circumstances including patients in the last days of life, birthing partners during labour, and parents or guardians supporting children in paediatric wards.
61. NHS England issued guidance on ‘Visiting healthcare inpatient settings during the COVID-19 pandemic’, which was updated several times. The guidance in place in January 2021 said visiting should be limited to ‘one close family contact or somebody important to the patient’, or ‘where social distancing can be maintained through the visit and if there are specific needs that have been agreed with the clinical team, up to four visitors could be permitted’. These circumstances could include where a patient was receiving end-of-life care.
62. The NHS England guidance included specific information about visiting patients who were dying. It said a balance was needed between ensuring close family members spent time with loved ones, and managing infection risk and maintaining the safety of the visitor, staff and other patients. It said organisations should use their own risk-based assessment to decide on visiting arrangements.
63. As outlined earlier, our role is not to ask whether an organisation could have done things better, or whether we agree or disagree with what it did. Instead, we look at whether there was fault in how the organisation made its decisions. If we decide there was no fault in the decision-making, we cannot ask whether the organisation should have made a particular decision or say it should have reached a different outcome.
64. In this case, the acute Trust said staff explained to Mrs O that her mother’s family was allowed to sit with her one at a time when she was nearing the end of her life, based on the visiting restrictions in that particular area of the hospital. It said the restrictions were led by the Trust’s Infection Control Team, and varied based on local ward and hospital infection rates. Mrs O disputes that they were told this.
65. I can appreciate how distressing it must have been for Mrs O and her family that these visiting restrictions were in place when her mother was dying. However, I have not seen fault in how the acute Trust reached its decision about visiting restrictions. The second wave of the COVID-19 pandemic reached its peak in January 2021 in England, and many infection control and social distancing measures were in place. The acute Trust’s actions were in line with guidance from NHS England on visiting healthcare inpatient settings and were based on information from its Infection Control Team and risk assessments.

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Final decision

66. I find no evidence of fault in the arrangements for Mrs W’s discharge from hospital to a care home, in her care at the Home, and in the arrangements for family to visit Mrs W when she was nearing the end of her life.

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Investigator's decision on behalf of the Ombudsman