Summary: We will not investigate Mrs B’s complaint about the way her mother, Mrs C, was discharged from a rehabilitation unit, and about her admission to and the discharge from hospital. This is because we would be unlikely to add to the responses Mrs B has already received from the organisations.

The complaint

1. Mrs B complains about treatment and care provided to her late mother, Mrs C. Specifically, Mrs B complains about a failed discharged from a rehabilitation unit, involving Sirona Care and the Council’s adult social care team. Mrs B says no care package was in place for her mother at home as it should have been, and as a result she had to return to the unit and was then admitted to hospital.
2. Mrs B also complains about Mrs C’s subsequent admission to hospital, managed by University Hospitals Bristol and Weston NHS Foundation Trust (the Trust). She says the Trust should have put Deprivation of Liberty Safeguards (DoLs) in place for Mrs C when she first went into hospital, and should have involved her more in discussions about her care. She also complains Mrs C should not have been discharged from the hospital to the care home, as it could not meet her needs.
3. Mrs B said there was an impact on her own mental health, and that she was shocked and devastated by what happened. Mrs B explained she feels sadness that Mrs C spent her final Christmas in isolation in an unfamiliar care home. Mrs B also said there was a financial impact on the family.
4. As an outcome of her complaint, Mrs B seeks service improvements and for the organisations to learn from the complaint, in terms of how they listen to patients’ families. Mrs B wants to know if service improvements that the organisations said would be put in place were implemented. Mrs B also seeks financial remedy.

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The Ombudsmen’s role and powers

5. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. 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).
6. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe:

• it is unlikely they could add to any previous investigation by the bodies, or
• they cannot achieve the outcome someone wants. (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

7. I considered information provided by Mrs B, and the complaint responses from Sirona Care and the Trust.
8. Mrs B had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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My assessment

9. As Mrs B has complained about discharge from the rehabilitation unit (Sirona Care) and admission to Bristol Royal Infirmary (managed by the Trust), I have set these out under separate headings, below.

Discharge from Sirona Care

10. Mrs C was ready to be discharged from the rehabilitation unit, managed by Sirona Care. Discharge planning was done by the multi-disciplinary team (MDT) on the unit, involving Sirona Care and the Council’s adult social care team. Mrs C was due to go home with a package of care in place. However, when Mrs C arrived home, the care package had not been arranged, and Mrs C had to return to the rehabilitation unit. Mrs B explained the impact this had on Mrs C, who had dementia.
11. In its response to Mrs B’s complaint, Sirona Care accepted that discharge plans were not put in place as they should have been. It said the discharge service would usually confirm all arrangements were in place before the patient left the unit, but said that in Mrs C’s case, this did not happen. I understand Mrs B did not complain to the Council, but Sirona Care’s response included information from the social care records, and shared learning with the MDT. It said there had been a communication breakdown between its staff and the wider team involved in the discharge process. Sirona Care apologised for the error and for any distress and confusion caused.
12. Sirona Care said following Mrs B’s complaint, it carried out a significant event analysis with the MDT. It said it had provided training for staff and had developed a new discharge checklist involving the MDT, to ensure all essential requirements were in place for the person before discharge. Based on the information I have seen, this is a reasonable response to Mrs B’s complaint, and an investigation would be unlikely to add anything further to this response for Mrs B.

Admission to Bristol Royal Infirmary

13. After Mrs C returned to the rehabilitation unit, she became unwell and was admitted to a hospital ward at Bristol Royal Infirmary, managed by the Trust. Mrs B complained that DoLs should have been put in place for Mrs C while she was on the ward. She also complained the Trust did not involve Mrs C in discussions about her care.
14. The Trust accepted DoLs should have been put in place when Mrs C was admitted to hospital. The Trust said a DoLs assessment was done after a week, but said it should have been done earlier, and that the Trust should have told Mrs C’s family about this assessment. The Trust said it would carry out training to improve knowledge of DoLs on the ward. The Trust apologised to Mrs B for any unnecessary distress caused.
15. On involving Mrs C in discussions about her care, the Trust apologised for not asking Mrs C to come to a Best Interests meeting. It said Mrs C had been able to come to the meeting after Mrs B supported her to do so.
16. Based on the information I have seen, the Trust responses on the issues of DoLs and involving Mrs C in discussions appear reasonable. An investigation is unlikely to add anything further on this point for Mrs B.
17. Mrs B also complained the Trust discharged Mrs C to a care home that did not have the equipment she needed, and where she could not have visitors over Christmas.
18. In October 2021, the Government updated its guidance for hospital discharge and social care assessments. This guidance was in place when Mrs C was discharged from hospital in December 2021. The guidance says discharge will be organised as soon as it is clinically appropriate. The Trust response says it had assessed Mrs C as medically fit for discharge. Therefore it is unlikely we would find fault with the Trust for deciding to discharge Mrs C once she was assessed as medically fit for discharge.
19. Mrs B complained the care home Mrs C went to was not suitable, as it did not have the equipment she needed, and she was unable to have visitors. In its response to Mrs B, the Trust said therapists had recommended Mrs C have a Sara Stedy mobility aid or a hoist. The Trust said based on this, information from clinical staff and from the Best Interests meeting, it was decided the care home was appropriate. The Trust clarified that Mrs C was discharged in line with Pathway 3 of the guidance, which meant Mrs C would have further assessment of her care needs in a care home. The Trust said that when a person is discharged on Pathway 3, the care home allocated may not be the home the person stays in long-term. It should be able to meet the person’s needs on a temporary basis so that an assessment of long‑term needs can take place.
20. The Trust accepted this was not made clear to Mrs B at the time and apologised for any stress this caused. I recognise Mrs B’s view about the impact on both her and Mrs C of Mrs C spending Christmas in the care home, and Mrs B’s explanation of how distressing this was. However, the Trust has provided a reasonable explanation for the decision, which is in line with the guidance in place at the time. Therefore an investigation would be unlikely to add to the explanation Mrs B has already received from the Trust.

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Final decision

21. We will not investigate Mrs B’s complaint about Sirona Care, the Council, and Mrs C’s admission to the Trust from October to December 2021. An investigation would be unlikely to add to the responses Mrs B has already received from the organisations.

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Investigator's decision on behalf of the Ombudsman