Summary: I found fault by the Trust in terms of their communication with Mr Y’s family and their planning for his discharge from hospital. This meant Mr Y was discharged without appropriate care in place. The Trust will apologise and pay Mr Y and his daughter, Mrs X, a financial remedy. They will also take appropriate remedial action to prevent similar problems occurring in future.

The complaint

1. Mrs X is complaining about the care and treatment provided to her father, Mr Y, by Thurrock Council (the Council) and Mid and South Essex NHS Foundation Trust (the Trust) during a hospital admission in early 2024. Mrs X complains that:

• the Trust failed to recognise that her father had sustained a broken back following a fall;
• the Trust said her father had sustained bruising as a result of slipping from his chair, but her father said he had been dropped by staff as they helped him out of bed;
• the Trust failed to provide her father with appropriate inpatient care, including pressure ulcer care, nutritional care and personal care;
• the Council and Trust failed to recognise the impact of her father’s pain relief medication on his ability to make decisions about his care; and
• the Council and Trust discharged her father home without putting appropriate care in place for him.

2. Mrs X says this meant her father was discharged home without appropriate care in place and in very poor condition. She says this affected his recovery and that he has been unable to completely regain his full strength and functioning.

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The Ombudsmen’s role and powers

3. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
4. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we 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).
5. 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.
6. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(1), as amended)

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How I considered this complaint

7. I considered evidence provided by Mrs X, the Council and the Trust. I also considered relevant law, policy and guidance.
8. All parties had an opportunity to comment on my draft decision. I considered all comments before making my final decision.

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What I found

Relevant legislation and guidance

Hospital Discharge

9. In April 2022, the Department of Health and Social Care issued statutory guidance entitled ‘Hospital discharge and community support guidance’ (the National Discharge Guidance). This provides guidance to NHS bodies and local authorities on discharging adults from hospital. This guidance was subsequently updated in January 2024.
10. The National Discharge Guidance notes that “[family members, friends and other unpaid carers play a vital role in the care of people who are discharged from acute and community settings.” It goes on to refer to the Health and Care Act 2022. This Act places a duty on NHS trusts to involve patients and unpaid carers as soon as is feasible in discharge planning for adults who are likely to need care and support following their discharge.

Mental Capacity Act 2005

11. The Mental Capacity Act 2005 (the MCA) applies to people who may lack mental capacity to make certain decisions. Section 42 of the MCA provides for a Code of Practice (the Code) which sets out steps organisations should take when considering whether someone lacks mental capacity.
12. Both the MCA and the Code start by presuming individuals have capacity unless there is proof to the contrary. The Code says all practicable steps should be taken to support individuals to make their own decisions before concluding someone lacks capacity. The Code says people who make unwise decisions should not automatically be treated as not being able to make decisions. Someone can have capacity and still make unwise decisions.

Clinical guidelines – pressure ulcer prevention and management

13. The National Institute for Health and Care Excellence (NICE) produces a guideline entitled ‘Pressure ulcers: prevention and management [CG179]’.
14. The guideline recommends a risk assessment to determine whether a person is at high risk of developing a pressure ulcer. A person at high risk will ordinarily have multiple risk factors, such as significantly reduced mobility, nutritional deficiency or an inability to position themselves.
15. The guidelines recommend encouraging adults who have been identified as at risk of developing a pressure ulcer to change their position frequently. In addition, the guideline recommends the use of pressure redistributing devices or products, such as air mattresses and barrier creams.
16. The guideline also provides guidance for the management of pressure ulcers. The guideline says clinical staff should measure and categorise the ulcer. With regards to wound dressings, section 1.4.23 says clinical staff should “[d]iscuss with adults with a pressure ulcer and, if appropriate, their family or carers, what type of dressing should be used.”

Care Act - safeguarding

17. Section 42 of the Care Act 2014 says that a council must make necessary enquiries, or cause others to do so, if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean they cannot protect themselves. It must also decide whether it, or another person or agency, should take any action to protect the person from abuse or risk. These are often known as ‘section 42 enquiries’.

Background

18. Mr Y attended the Emergency Department at Basildon University Hospital on 23 February 2024. He was experiencing some left hip pain following a fall at home. He was admitted to a ward the following day.
19. A Computerised Tomography (CT) scan undertaken on 28 February revealed that Mr Y had sustained a fracture in one of the vertebrae in his lower back. The clinical team treated him with pain medication and a lower back brace.
20. On 7 March, nurses noted Mr Y had developed wounds on his forearms caused by rubbing them against the arm of his chair. The nurses dressed
21. At 10.00pm on 13 March 2024, Mr Y suffered a fall. In the care notes, it is recorded that he had slipped unwitnessed from his chair to the floor. However, this remains a point of dispute. Mrs X says Mr Y told her a care worker had dropped him when assisting him out of bed. Mrs X said this had been confirmed by another patient on the ward.
22. A further CT scan revealed the previous vertebral fracture, but no new injuries.
23. The clinical team treating Mr Y decided on 20 March that he was medically optimised for discharge. This meant there was no clinical reason for him to remain in hospital.
24. On 22 March, a social worker spoke to Mr Y on the ward. She noted that Mr Y had declined a care package.
25. However, later that day, Mrs X contacted the Council to say that Mr Y would need assistance with washing, dressing and toileting. Mrs X also noted that Mr Y’s hospital stay had affected his mental health and that his personality had changed dramatically.
26. The Council completed a joint visit to Mr Y with a member of therapy team on 25 March. The visiting officers arranged a care package for Mr Y and ordered some additional equipment, such as a new walking frame and raised toilet seat. The attending physiotherapist also referred Mr Y for a course of physiotherapy. The Council officer noted that the physiotherapist shared the family’s view that this had been an unsafe discharge.
27. In April, the Trust made section 42 enquiries at the direction of the local safeguarding authority. The enquiries found hospital staff had not made Mr Y’s family aware of his pressure ulcers and the fact that he was not complying with attempts to treat them.
28. The local safeguarding authority found better support planning, involving Mr Y’s family, could have clarified his care needs prior to discharge. The safeguarding authority concluded that “the unsafe discharge could have been avoided.”

My findings and analysis

Diagnosis

29. Mrs X complains that the Trust failed to recognise Mr Y had sustained a broken back following his fall.
30. The Trust said Mr Y had undergone an X-ray of his left leg and hip when he attended the Emergency Department (ED) in February 2024. This did not reveal a fracture. However, the Trust acknowledged the X-ray did not include the entirety of Mr Y’s lumbar spine area, where he had suffered a fractured vertebra.
31. The Trust said it was working towards Mr Y’s discharge. However, he continued to report pain in both hips and difficulty bearing his weight. This led the Trust to undertake a CT scan of the pelvis and hip. This revealed the fracture. The Trust treated this with the use of a lumbar brace and referred Mr Y to its neurological centre for follow-up.
32. The clinical notes for Mr Y’s initial attendance at the hospital Emergency Department record that he was complaining of hip pain following his fall at home. Mr Y’s clinical history showed that he had previously received hip replacements on both legs. The clinical team recorded a suspected diagnosis of “[c]ontusion of pelvic region”.
33. This led the team to complete a pelvic X-ray. The X-ray revealed mild loss of bone density, but no fractures. The clinical team treated Mr /Y with pain relief medication.
34. Shortly before 3.00pm on 24 February, the therapy team assessed Mr Y to establish whether he would be able to return home on discharge. However, the therapists stopped the assessment as Mr Y was complaining of pain. The therapist noted that Mr Y was “not keen on going home” and noted that he may not be safe there due to the stairs.
35. The therapy team continued to review Mr Y and he received regular pain relief medication. On 27 February, a nurse noted that Mr Y continued to experience “on and off” pain.
36. The Trust completed a CT scan on 28 February. This included the lumbar spine area, which had not been covered by the initial pelvic X-ray. The CT scan revealed that Mr Y had suffered a fractured vertebrae in his lower back.
37. In my view, it was appropriate for the Trust’s initial investigations to focus on Mr Y’s pelvis and hip area. This is because the clinical records show Mr Y was complaining of pain in his left hip. Further, Mr Y had a history of hip surgery. When the X-rays did not reveal an injury, the Trust’s therapy team began a process of assessment. Again, this was in keeping with good clinical practice. When Mr Y continued to complain of pain, the Trust undertook further investigations, which revealed the fracture. The evidence I have seen shows this was a robust process of diagnosis and I found no fault by the Trust in this matter.

Fall

38. Mrs X says the Trust claimed her father had sustained bruising as a result of slipping from his chair. However, Mr Y said he had been dropped by staff as they helped him out of bed. Mrs X said that, when Mr Y came home, he had a bruise all down his right thigh and bottom that he must also have suffered when he fell.
39. The Trust said Mr Y had slipped from his chair but did not hit his head. The Trust said an on-call doctor assessed Mr Y and that a CT scan showed no new injuries. The Trust said Mr Y did not initially show any signs of bruising but had started to develop some on his right lower back and bottom within around 48 hours.
40. The evidence I have seen shows there is some dispute as to the circumstances surrounding Mr Y’s fall on 13 March.
41. At 10.21pm, shortly after Mr Y’s fall, a doctor noted in the contemporaneous clinical records “patient reports not falling or hitting anything. He reports slowly slipping from chair. Didn’t hit his head or hip.”
42. A nurse who spoke to Mr Y at 11.00pm recorded that Mr Y “[v]erbalised he was trying to transfer himself from bed to chair, slowly slid off from bed to the floor.” The nurse also noted that Mr Y denied having hit his head or back. The nurse also completed an incident report, which recorded the same details.
43. These accounts contradict what Mr Y told his family, which was that he had been dropped by a carer who was assisting him from his bed. Mrs X said this was confirmed by another patient on the ward.
44. We are therefore presented with different accounts of the circumstances surrounding the fall. In the absence of any further evidence, I am unable to say what occurred, even on balance of probabilities.
45. I have considered whether the clinical staff responded appropriately following the fall. The clinical records show a doctor reviewed Mr Y around 20 minutes after the fall. The doctor noted that Mr Y did not appear to have suffered any injuries from the fall and was not complaining of any new pain. The doctor also assessed Mr Y using the Glasgow Coma Scale (GCS). This is a neurological scale used to assess a person’s level of consciousness. The GCS uses scores ranging from 3 (a deep coma) to 15 (fully awake). The doctor scored Mr Y as 15 on the GCS. The clinical records show the doctor planned to repeat hip and pelvis X-rays to check for injury. However, a subsequent CT scan did not identify any injury beyond his back fracture.
46. The nurse who saw Mr Y around an hour after his fall took further clinical observations, which were within normal ranges. The nurse again scored Mr Y as 15 on the GCS.
47. Trust staff also completed a post-falls protocol. This is effectively an electronic checklist setting out the patient’s clinical profile following a fall. In addition, the incident report makes clear that Mr Y had been moved to a more visible area on the ward and staff ensured his call bell was in reach.
48. The evidence shows Trust staff appropriately assessed Mr Y following his fall and were satisfied there was no evidence of any head injuries or other significant injuries at that time. This was in keeping with good clinical practice and I found no fault by the Trust in how they monitored Mr Y immediately after his fall.

Pain relief medication and capacity

49. Mrs X says the Council and Trust failed to recognise the impact of Mr Y’s pain relief medication on his ability to make decisions about his care and that they caused him to be sick.
50. The Trust said Mr Y had been treated with regular paracetamol, as well as oral Oramorph (a liquid morphine painkiller) when required. The Trust said this was supervised by the Pain Team.
51. I have considered this issue first as concerns around Mr Y’s capacity to make decisions about his care are relevant to other aspects of this complaint.
52. The clinical records show Mr Y was complaining of pain on admission and required pain relief medication to treat this. These are recommended treatments for moderate to severe pain. On 28 February, a doctor noted that Mr Y felt the Oramorph medication was helping. I find no fault by the Trust with regards its decision to prescribe pain relief medication for Mr Y. This was in keeping with good clinical practice.
53. While morphine is an effective treatment for severe pain, nausea and vomiting are recognised side effects of this medication. The clinical team treated these symptoms with antiemetic medications (drugs to treat nausea) when required. Again, this reflected good clinical practice.
54. I found no fault by the Trust with regards to the medication administered by the clinical team.
55. Mrs X was particularly concerned that the strong pain relief medication Mr Y was taking affected his ability to make decisions about his care. This was potentially significant as Mr Y was declining many care interventions (such as wound dressing).
56. The MCA and accompanying Code work from a presumption of capacity. This means a person should be treated as having the capacity to make decisions unless it is established that they do not.
57. In the clinical records, staff regularly recorded that Mr Y appeared alert and orientated and was able to recall the circumstances surrounding the fall that prompted his admission. On 24 February, a therapist noted a detailed discussion with Mr Y about discharge options.
58. During the morning of 12 March, a nurse noted that Mr Y was “alert and settled but confused.” A similar note the following day recorded “alert and occasionally confused”.
59. The MCA and Code emphasise that every adult has a right to make their own decisions, even if others (such as care professionals or relatives) consider those decisions unwise. This would include Mr Y’s decision to refuse care on occasions.
60. The clinical records show Mr Y could be confused at times. However, he was generally noted to be alert and orientated to time and place. I found no evidence to suggest the care team had any concerns about Mr Y’s ability to make decisions about his care. In the circumstances, professionals acted appropriately in assuming that Mr Y had capacity to make decisions about his care. This was in keeping with the requirements of the MCA and Code. I find no fault by the Trust on this point.
61. Nevertheless, I do have related concerns about the handling of Mr Y’s discharge. I have outlined these in the ‘discharge’ section of this decision statement.

Inpatient care pressure ulcer care

62. Mrs X says the Trust failed to provide her father with appropriate inpatient care. This included pressure ulcer care.
63. The Trust said Mr Y was found to have a Grade 2 pressure ulcer on his right buttock on 28 February. In addition, the Trust found Mr Y had developed wounds on his forearms and elbows due to rubbing them on the arms of his chair. The Trust said staff photographed and dressed the wounds. The Trust said Mr Y refused an air mattress and sometimes refused to have his wounds dressed.
64. Mr Y was admitted to the ward on 24 February. The admission record notes that his pressure areas (area of the body that are prone to pressure sores, such as the heels, elbows and tailbone) were intact at that point.
65. An assessment undertaken on 23 February had found Mr Y could not fully weight bear. The Trust completed a moving and handling assessment and care plan for him. This noted Mr Y required assistance to transfer from his bed to his chair. It also noted Mr Y preferred to remain in his chair most of the time and was able to reposition himself in it.
66. At 3.10pm on 28 February, a nurse noted that Mr Y “has a category 2 on his right buttock”. This refers to a category 2 pressure ulcer. Pressure ulcers are graded into six categories. A stage 2 pressure ulcer will typically appear as a shallow open ulcer, abrasion or blister. The nurse dressed the ulcer. Mr Y said this predated his admission. However, this seems to be contradicted by the admission notes.
67. On 4 March, a nurse noted that Mr Y had refused an air mattress on the basis that he wanted a hard mattress. The nurse noted she had explained the importance of an air mattress. However, Mr Y continued to decline this equipment.
68. Mr Y continued to complaint of back pain. However, he remained keen to sit out in his chair as much as possible. On 8 March a nurse tried to persuade Mr Y to use a recliner chair, but he declined.
69. On the same day, a nurse noted that Mr Y had developed pressure wounds on both forearms as a result from rubbing them against the arms of his chair. However, Mr Y was variable from day to day in terms of whether he would allow staff to dress the wounds.
70. A member of Trust staff spoke to Mrs X on 13 March to update her on Mr Y ‘s condition. However, she did not mention the pressure sores. This was an oversight and represents fault by Trust. This meant Mrs X was caused distress when she saw the wounds following Mr Y’s discharge. However, I am satisfied the Trust acknowledged and apologised for this in its complaint response. In my view, this is an appropriate remedy to the injustice caused to Mrs X.
71. At the point of discharge, the Trust referred Mr Y to the district nursing service for ongoing management of the wounds on his arms and sacral area in the community.
72. I am satisfied the pressure ulcer care provided by the Trust was appropriate and in keeping with good clinical practice.

Inpatient care - Nutrition

73. Mrs X says the Trust failed to provide her father with appropriate inpatient care. This included nutritional care. Mrs X said Mr Y lost a significant amount of weight during his admission as a result.
74. The Trust acknowledged that Mr Y had been sick at times and that this made him unwilling or unable to eat all his meals. The Trust said it treated Mr Y with antiemetic medication (to prevent him being sick) and encouraged him to eat, including offering him nutritional shakes. The Trust added that Mr Y’s call bell was left where he could reach it in case he was hungry.
75. The case records support the Trust’s complaint response. There are numerous entries in the records to suggest Mr Y regularly refused to eat meals. This was because he reported feeling sick as a result of his medication. As above, the Trust was working to manage this with antiemetic medications. Nevertheless, Mr Y did lose weight during his admission (around 5 kilograms) between 26 February and 17 March
76. The Trust also began to maintain food charts for Mr Y as he was recognised to be at greater risk of malnutrition as his admission proceeded. The evidence I have seen suggests Trust staff were regularly encouraging Mr Y to eat and supporting his intake with nutritional supplements where possible.
77. However, even though staff had detailed conversations with Mr Y’s family on 13, 15 and 19 March, they do not appear to have made them aware he was refusing meals. This was important information and omission by Trust staff. This was fault.
78. I am unable to say whether the involvement of Mr Y’s family in this aspect of his care would have prevented him from refusing meals. Nevertheless, it represented a missed opportunity. This had an impact on Mr Y’s nutritional care and caused Mrs X distress when she later found out.

Inpatient care - Personal care

79. Mrs X said that, when her brother visited Mr Y on 20 March, he found him dirty and unshaven.
80. The Trust’s response said staff did assist with personal care and apologised if the family had found him to be dirty. It said it had fed this back to the ward.
81. I have reviewed the care plans for Mr Y’s admission. These show Mr Y needed assistance to move to the toilet and with his personal care. The nursing notes show staff were regularly assisting Mr Y with his personal care, although he sometimes refused this assistance. Overall, I found no pattern of omission or inaction by Trust staff in terms of Mr Y’s personal care, and I found no fault on this point.
82. Nevertheless, I recognise it would have been distressing for Mr Y’s family to find him dirty when they visited. The Trust apologised for this in its complaint response, and I consider this an appropriate remedy.

Discharge

83. Mrs X complains that the Council and Trust discharged her father home without putting appropriate care in place for him.
84. The Trust said Mr Y had declined a package of care and had been provided with details for the Council in case he changed his mind. The Trust said Mr Y had also been referred to the District Nursing service for wound care and administration of his pain relief medication.
85. A doctor spoke to Mrs X on 13 March to talk through his care. The doctor noted that Mrs X felt Mr Y would require a package of care on discharge as he would be unable to cope at home on his own. The doctor advised that the Trust’s therapy team would assess Mr Y and decide what support he would need.
86. A member of the ward team spoke to Mrs X again on 15 March. Mrs X asked again about discharge arrangements and care packages. However, the doctor said Mr Y was not well enough for discharge at that point. He again provided assurance that the therapy team would be assessing Mr Y.
87. This assessment took place on 19 March. However, the therapist noted it had been difficult to properly assess Mr Y as he largely declined to participate in physiotherapy exercises because of pain. Mr Y asked the therapy team to speak to Mrs X to obtain more information about his home situation. Somebody from the Trust did call Mrs X later that day. The member of staff advised that there had been plans to discharge Mr Y that day but that he had described having a bad night. As a result, the clinical team wanted to wait until he felt better.
88. On 20 and 21 March, ward staff spoke again with Mr Y’s family. The family were keen to have him return home as soon as possible as they felt he was deteriorating in hospital.
89. On 21 March, it was noted that Mr Y would require a care package entailing four daily care visits to support him at home, as well as some equipment.
90. A Council social worker visited Mr Y on the ward on 22 March to discuss a care package. The social worker noted Mr Y said “he was able to manage all his care needs by himself. He was asked several times and firmly declined support being put in place on discharge.”
91. Mr Y was discharged later that day without a care package. Mr Y’s family contacted the Council’s community team later that day to report that he could not cope without support. This led to a joint visit and care and support was put in place shortly afterwards.
92. This handling of Mr Y’s discharge was the specific subject of section 42 enquiries undertaken by the Trust on behalf of the local safeguarding authority. These enquiries identified that there had been a lack of engagement with Mr Y’s family around his discharge and (care more generally). This meant Mr Y was ultimately discharged without care and support in the community. The enquiries found Mr Y declined support as he thought this was the only way his discharge would proceed. The enquiry concluded that confusion around this might have been avoided with better support planning involving Mr Y’s family.
93. It is important to be clear that Mr Y did decline a package of care prior to discharge. As above, he was considered to have capacity to make this decision and maintained his position despite being asked several times. It should also be noted that face to face communication was made more challenging by an infection that required the ward to be locked down.
94. Nevertheless, I share the safeguarding enquiry’s view that, more effective planning work involving Mr Y’s family might have uncovered the confusion underlying his decision to refuse a care package. This is turn would likely have prevented his discharge without support. The failure to work more closely with Mr Y and his family represented fault by the Trust. This caused Mr Y and Mrs X avoidable frustration and distress.
95. I have not made a finding of fault against the Council as it only became involved on the day of discharge, by which point the opportunity for more effective discharge planning had passed. I also note the Council acted swiftly to put appropriate care in place when approached by Mr Y’s family.

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Action

96. Within two months of my final decision, the Trust will write to Mr Y and Mrs X to apologise for the injustice caused to them by its failure to:

• inform her Mr Y had developed pressure ulcers during his admission and keep her updated about the treatment of these;
• inform her that Mr Y was refusing his food and involve her in supporting him with this aspect of his care, as appropriate; and
• to involve Mrs X properly in planning for Mr Y’s discharge from hospital.

97. The Trust will also pay Mrs X and Mr Y £200 each (£400 in total) in recognition of the injustice caused to them by the fault I identified.
98. Within three months, the Trust will write to the Ombudsmen to explain what action it will take to ensure its discharge policies and procedures reflect the need to involve key family members and carers in the discharge planning process where appropriate.
99. The Trust should provide us with evidence it has complied with the above actions.

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Decision

100. I found fault causing injustice by the Trust in this case. The Trust will carry out the above actions to remedy this injustice.
101. I found no fault by the Council in this case.

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Investigator's decision on behalf of the Ombudsman