Summary: The Ombudsmen consider Southend University Hospital NHS Foundation Trust (the Trust) should have referred Mrs G to its Collaborative Care Team. This caused uncertainty to Mr G by not knowing if the referral would have improved Mrs G’s rehabilitation. The Ombudsmen also consider the Trust and Essex County Council’s lack of communication on discharge also caused Mr G confusion. He did not know who was going to meet Mrs G’s mobility needs.

The complaint

1. Mr G complains that Southend Hospital University NHS Foundation Trust (the Trust) did not provide physiotherapy/mobility care on the ward to his wife, Mrs G, after she fractured her arm. He says the Trust should have referred Mrs G to its Collaborative Care Team (CCT) to provide support on discharge. Instead, the Trust referred Mrs G to Essex County Council (the Council) who commissioned a care agency, Brooks, to provide reablement care at home.
2. Mr G says the Trust and Council’s lack of support caused Mrs G’s fracture to misalign and she suffers constant pain. Mr G also says events caused him great distress as he is Mrs G’s sole carer.
3. Mr G says Brooks’ care and support did not meet his wife’s mobility needs. Also, the Council did not say it would charge Mrs G after six weeks of reablement care.
4. Mr G would like an apology, for both organisations to provide a care package which meets Mrs G’s needs to enable her to walk independently. Also, to avoid similar fault reoccurring.

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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. 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. The Ombudsmen cannot decide what level of care is appropriate and adequate for any individual. This is a matter of professional judgement and a decision the relevant responsible body has to make. Therefore, my investigation has focused on the way the body made its decision.
8. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened.
9. 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)

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How I considered this complaint

10. I considered information Mr G and his daughter provided in writing and by telephone. This includes documents by the organisations complained about. I have provided Mr G and his daughter with two draft versions of this statement and consider their comments.

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What I found

Key facts

11. The Trust admitted Mrs G on 18 January 2019 after she had fallen and fractured her elbow. During the admission, Mr G said his wife had been in bed for too long and the Trust should be providing physiotherapy. The Trust agreed to complete a rehabilitation assessment by an occupational therapist.
12. On 24 January, an occupational therapist could not assess Mrs G’s ability to transfer as she was sleepy. However, a physiotherapist would try to review Mrs G again before the Trust discharged her. The occupational therapist also said: “[Mrs G] may well need a hospital bed at home because all care is being given on the bed. This would mean that carers would be required to give personal care” and “[the CCT] would be required due to unstable fracture”.
13. The next day a physiotherapist reviewed Mrs G. She said Mrs G was agitated when changing so it would not be safe for her transfer out of bed.
14. On 28 January, the Trust’s discharge team told the Council it was going to discharge Mrs G on 30 or 31 January.
15. The next day, the occupational therapist told Mr G “we had tried to get her out of bed, but we had not been able to gain her co-operation to do this”. The occupational therapist agreed to refer Mrs G for physiotherapy on discharge. On the same day, a social worker (based at the Trust) contacted care companies to support Mrs G on discharge. The care package consisted of four calls a day for 30 minutes. The social worker said carers should promote Mrs G’s independence by encouraging her to mobilise. Brooks agreed to provide that care.
16. The Trust discharged Mrs G home on 31 January and referred her to a physiotherapist. Brooks also assessed Mrs G on that day and did not include support for Mrs G’s mobility in its care plan.
17. A district nurse and an occupational therapist referred Mrs G to a physiotherapist on 3 February.
18. On 7 February a different occupational therapist (the OT) told the social worker Mrs G could mobilise with Mr G’s support, but Brooks were not helping her out of bed.
19. A week later the OT and a physiotherapist reviewed Mrs G. They noted Mrs G could sit on the end of the bed independently and needed help from two people to stand from sitting, and to walk four to five steps. Mrs G also had trouble following some verbal instructions.
20. During an outpatient appointment on 22 February a consultant said Mrs G’s fracture had only partially healed. Mrs G needed to start mobilising, including sitting up in a chair, and should not have been nursed lying down. Rather, she should have been sitting vertically for the fracture to heal properly. The consultant referred Mrs G to a physiotherapist.
21. On 7 March the OT and the physiotherapist reviewed Mrs G. They noted Mrs G could mobilise and the physiotherapist referred her to the CCT. She could move from the bed to stand up and walk with the support of others. Around the same time, Mr G’s daughter was also asking the CCT to review Mrs G.
22. A week later, Mr G’s daughter raised safeguarding concerns to the Council about Mrs G, including her lack of mobility.
23. On 18 March the Council visited Mr G to carry out an assessment of Mrs G’s needs. This was because the reablement package had ended. A social worker advised Mr G of the charging policy for care and support, since the six weeks of reablement care had formally ended. Mr G declined social care support for Mrs G as she had funds over the threshold, and he would arrange her care privately. The Council decided to not charge Mrs G for her care after that point.
24. A week later the CCT agreed to take over Mrs G’s care from Brooks and to assess Mrs G’s rehabilitation potential. The next day Mr G’s daughter told the Council the Trust should have referred Mrs G to the CCT before it discharged Mrs G.
25. The Council’s safeguarding meeting on 29 March noted there were mistakes in Mrs G’s care, including:
• The Trust should have referred Mrs G to the CCT.
• Brooks were not qualified to manage Mrs G’s unstable fracture.
• If the CCT was aware of the referral, it would have given Mrs G goals to improve her mobility within 24 hours of assessing her.
• The social worker’s assessment and decision making was appropriate for Mrs G’s needs.
• Brooks’ care and treatment was appropriate when it nursed Mrs G in bed.
26. On 10 April, a community physiotherapist noted Mrs G could sit down independently and could mobilise with support from two people. As CCT are managing Mrs G, the physiotherapist discharged Mrs G.
27. During an outpatient appointment on 30 April, a consultant said the physiotherapist was making slow progress with Mrs G. Also, Mrs G would need physiotherapy and support to carry on mobilising.
28. The CCT later discharged Mrs G as they had improved her mobility, and a care agency could support her. Mrs G could sit on the edge of the bed, stand, and mobilise with help from one person. However, Mrs G would need support from two people to improve her wellbeing and independence. Until that point, Mrs G had not paid anything towards her care.

Analysis

The Trust’s care and treatment for Mrs G’s mobility

29. I have reviewed the Trust’s medical records.
30. The Trust tried to get Mrs G out of bed and mobilising. However, when it tried to mobilise Mrs G she could not do so. This was for various reasons, including Mrs G’s agitation, confusion and her lack of co-operation. Mrs G had fallen recently and was unwell. While Mr G feels strongly his wife should have been mobilising more, the medical records show she was not able to, despite the Trust’s efforts. I understand why the Trust did not want to risk Mrs G mobilising on the ward. Therefore, I do not consider the Trust’s care and treatment was fault.

The lack of a referral to the Trust’s CCT

31. The CCT are a community-based rehabilitation service, which provide goal-based rehabilitation in people’s homes to prevent re-admission.
32. In response to my enquiries, the Council was under the impression the Trust was responsible for managing Mrs G’s mobility because that was a health need. I understand why the Council believed that. The Trust had already made two referrals – to the CCT (which it did not follow up) and a physiotherapist to review Mrs G’s mobility.
33. I consider the Trust’s lack of referral to the CCT was fault. The CCT were best placed to assess Mrs G’s mobility needs considering her recent fracture. This was a missed opportunity. The Trust said if it referred Mrs G to the CCT, the CCT would have created a plan to manage Mrs G’s rehabilitation.
34. A physiotherapist was keeping Mrs G’s mobility under review until the CCT took over Mrs G’s care two months after the Trust discharged Mrs G. However, I cannot say, even on the balance of probabilities, if the outcome of Mrs G’s rehabilitation would have been different if not for the two‑month delay. I cannot determine what support the CCT would have provided to support Mrs G’s rehabilitation from the fracture. This has caused Mr G uncertainty. Also, Mr G’s daughter went to time and trouble chasing the CCT to support Mrs G.
35. The Trust has accepted the fault and apologised to Mr G. However, the Trust needs to do more to remedy the injustice Mr G suffered.

The reablement care package

36. Reablement is a community based short-term service offered by councils which offers intensive support in the person’s home. Reablement helps individuals regain skills, confidence, and independence around their daily living skills, community access, and integration. Reablement service users have a social care need and support services are usually provided for up to six weeks. If a council arranges Reablement in the person’s own home, councils have discretion whether or not to charge. If necessary, the initial reablement period after discharge from hospital can be used to ensure that an assessment is completed, and any further services are arranged.
37. Mr G said Brooks’ care and support did not meet his wife’s mobility needs.
38. I have reviewed the social worker’s needs assessment and her referral to Brooks.
39. In the referral, the social worker noted Mrs G was “...nursed in bed” at the Trust, which was true. In Brooks’ assessment of Mrs G, they frequently noted Mrs G should be nursed in bed. I do not consider Brooks was at fault for nursing Mrs G in bed. That was in line with both the social worker and the OT’s assessments of Mrs G at the Trust.
40. Brooks’ care package was created around Mrs G’s personal care needs. I consider Mrs G’s mobility needs got lost during the discharge process. I have already found the Trust missed the opportunity to refer Mrs G to the CCT. However, better communication between the social worker and the Trust’s discharge team would have clarified which organisation was responsible for managing Mrs G’s mobility needs on discharge.
41. There were four referrals to a physiotherapist, by different professionals. This showed it was not clear who was responsible for managing Mrs G’s mobility needs. This poor communication was fault.
42. If the Trust’s discharge team and the social worker discussed Mrs G’s mobility needs on discharge, it would have eased Mr G’s confusion when Mrs G returned home. I consider the Council and Trust should remedy the injustice Mr G suffered.
43. Mr G said the Council did not say it would charge Mrs G after six weeks of reablement care.
44. I have reviewed the social worker’s records from the time of the event.
45. Discussions about charging for reablement care should have started during the discharge process at the Trust. This did not happen in Mrs G’s case. The first time a social worker explained Mrs G’s care was chargeable was after the six weeks of non-chargeable care ended. This was fault.
46. While the six weeks of reablement care had formally ended, the Council did not charge Mrs G for another three weeks of care under Brooks. Also, the CCT provided another five weeks of non-chargeable care when it took over from Brooks. Therefore, I agree the Council missed an opportunity to discuss charging during the discharge process. However, I do not consider there is any injustice to Mr or Mrs G.

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Recommendations

47. Within four weeks:
• The Trust should apologise for the uncertainty and time and trouble Mr G and his daughter suffered by not referring Mrs G to the CCT when it should have.
• The Council and the Trust should apologise for the confusion Mr G suffered caused by their lack of communication about who would manage Mrs G’s mobility at home.
• The Council and Trust should each pay £250 in recognition of the uncertainty and confusion Mr G suffered.
48. Within eight weeks the Trust should develop an action plan to ensure it follows up referrals before (or after) it discharges people home.

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Final decision

49. I consider the Trust’s attempts to mobilise Mrs G on the ward were appropriate. However, it missed the opportunity to refer Mrs G to the CCT. This caused Mr G uncertainty, as he will not know what support his wife would have received to improve her mobility.
50. The Trust was responsible for managing Mrs G’s mobility needs. However, a lack of communication between the Council and Trust caused Mr G confusion when Mrs G returned home.
51. The Council should have explained to Mr G his wife would have to pay towards her reablement care after six weeks during the discharge process. However, there was no injustice to Mr or Mrs G as the Council did not charge for any care and support.

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Investigator's decision on behalf of the Ombudsman