Summary: Mr X complained about City of York Council (the Council) and York and Scarborough Teaching Hospitals NHS Foundation Trust (the Trust). Mr X complained about the way the Council and the Trust dealt with his late father, Mr Y’s, discharge from hospital and the Trust’s care of Mr Y while he was in hospital. We will not investigate the complaint because a coroner and a local Safeguarding Adults Board (SAB) are still investigating related issues. Mr X can resubmit his complaint to us for further consideration when the coroner and SAB have finished their investigations.

The complaint

1. The complainant, whom I shall call Mr X, complains about the actions of City of York Council (the Council) and York and Scarborough Teaching Hospitals NHS Foundation Trust (the Trust). Mr X complains about matters affecting his late father, Mr Y.
2. Mr X complains that:
• Mr Y’s discharge from hospital was delayed despite known staffing problems increasing the risks to Mr Y’s safety in hospital;
• the Trust did not monitor Mr Y as it should have while he was in hospital to reduce the risk of falls; and
• after a serious fall in hospital, the Trust delayed noticing Mr Y’s broken hip and providing medication for the resulting pain.
3. Mr X says this caused the following injustice.
• Mr Y had an unnecessarily prolonged stay in hospital, moving wards four times without medical justification for the moves. This caused him avoidable distress.
• Mr Y had a serious fall, breaking his hip and suffering a bleed on the brain which eventually led to his death. Mr X believes this would not have happened had there been no delay in the discharge process.
• Mr Y suffered unnecessary pain and distress for five days because the Trust did not notice he had broken his hip and failed to provide pain relief.
• Mr Y’s family suffered avoidable distress because of what happened to Mr Y.
4. Mr X would like evidence that the organisations have made effective service improvements to prevent similar problems affecting others.

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The Ombudsmen’s role and powers

5. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start an investigation if they believe it would be reasonable to wait for the outcome of investigations or reviews by other organisations before considering a complaint. (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

6. I have considered written information provided by Mr X, the Council and the Trust. I have also discussed the complaint with Mr X.

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What I found

7. Mr Y had dementia. He went into hospital after falling at home. When he became medically fit for discharge, his family wanted him to return to his own home. The hospital considered he could go home if he got more support there. The Council’s adult social care service had safeguarding concerns. Mr Y remained in hospital awaiting an agreed discharge plan. While still in hospital, Mr Y fell from his bed. A scan confirmed he had a bleed on the brain. Five days later, an x-ray confirmed he had broken his hip. Mr Y’s health worsened and he died a few days later.
8. Mr X complained about the circumstances leading to Mr Y’s death to the Council and Trust. He was dissatisfied with their responses so complained to us.
9. Mr Y’s death has also been reported to the coroner and the local Safeguarding Adults Board (SAB). Coroners are independent judicial office holders who investigate deaths in certain circumstances. SABs oversee adult safeguarding in their areas and include members from councils, the NHS and the police. In some cases where adults needing care have died, SABs can arrange a safeguarding adults review (SAR) with a view to:
• identifying the lessons to be learnt from the adult’s case; and
• applying those lessons to future cases.
10. Mr X has told us that:
• he is still waiting for the outcome of the coroner’s investigation; and
• the local SAB has recently told him it will carry out an SAR into his father’s case.
11. The Ombudsmen will not continue to consider this complaint while the coroner’s investigation and SAR are open. This is because:
• the organisations could end up unnecessarily duplicating work;
• having to respond to more than one investigation at the same time could place an unreasonable burden on Council and Trust resources, affecting services to the public; and
• the outcomes of the coroner’s investigation or SAR may provide Mr X’s desired outcome of effective service improvements, without the need for an investigation by the Ombudsmen.
12. Mr X can complain to us again if he has outstanding concerns once the coroner’s investigation and SAR are finished. We will then reconsider whether we can and should investigate his complaint.

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Final decision

13. We will not investigate this complaint because it is reasonable to wait for the outcomes of the safeguarding adults review and the coroner’s investigation. Mr X can resubmit his complaint to the Ombudsmen if he has outstanding concerns after the conclusion of the safeguarding adults review and the coroner’s investigation.

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Investigator's decision on behalf of the Ombudsman