Summary: We found fault with Lewisham and Greenwich NHS Trust’s handling of Mr C’s discharge from hospital in September 2023. This fault caused Mr C’s daughter, Mrs B, confusion and distress. The Trust will apologise to Mrs B and pay her a financial remedy. It will also take action to prevent similar problems occurring in future. We found no fault with the actions of London Borough of Bexley in the discharge process.

The complaint

1. The complainant, who I will call Mrs B, is complaining about the care and treatment provided to her father, Mr C, by London Borough of Bexley (the Council) and Lewisham and Greenwich NHS Trust (the Trust) in August and September 2023.
2. Mrs B complains that the Trust and Council discharged her father from hospital without a proper care plan in place and without any instructions for his GP. In addition, Mrs B complains that the Trust and Council failed to make appropriate referrals for Mr C to community services on discharge. Further, Mrs B complains that the Trust discharged Mr C without the medication he needed. Mrs B said the carers allocated to support Mr C at home were not properly trained.
3. Mrs B says this situation was extremely stressful for Mr C and the family. She says Mr C was left without adequate care, and that communication with community services was poor.

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The Ombudsmen’s role and powers

4. 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).
5. 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).
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. We cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. If there was no fault in how the organisation made its decision, 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))
8. 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

9. I considered evidence provided by Mrs B and discussed the complaint with her. I also considered relevant information and records from the Council and Trust. I took account of relevant law, policy and guidance.
10. 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

11. In April 2022, the Department of Health and Social Care issued statutory guidance around hospital discharges 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.
12. The National Discharge Guidance introduces an expectation that patients will be discharged in a timely way as soon as they no longer require treatment in an acute hospital. The National Discharge Guidance sets out various discharge paths. These include discharge home with a package of support and further assessment to determine the person’s long-term care needs.
13. The National Discharge Guidance records that “[p]alliative and end of life care needs should be anticipated and met as part of an individual’s discharge journey”. It goes on to say that “[i]information should be shared across relevant health and care teams and organisations across the system in a secure and timely way to support best outcomes.”
14. The National Discharge Guidance emphasises the importance of involving families and carers in the discharge process where appropriate.

Continuing Healthcare (CHC)

15. The government produces guidance around Continuing Healthcare (CHC) funding. This is entitled the ‘National Framework for NHS Continuing Healthcare and NHS funded Nursing Care’ (the CHC Framework).
16. CHC is a package of ongoing care that is arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’. For most people who may be eligible for CHC, the first step in assessment is for a health or social care professional to complete a CHC Checklist. The threshold for meeting the CHC Checklist is set low.
17. The CHC Framework states that where an individual is eligible for CHC funding, the local Integrated Care Board (ICB) is responsible for care planning, commissioning services and case management.
18. The CHC Framework explains that an individual with a rapidly deteriorating condition, which “may be entering the terminal phase” may require fast tracking for immediate provision of CHC services. In fast track cases, this decision is made by an ‘appropriate clinician’. This is ordinarily a nurse or medical practitioner responsible for the care of the individual involved.
19. The CHC Framework says the term “rapidly deteriorating” should not be interpreted narrowly as only meaning an anticipated specific or short time frame of life remaining”. It also says that the term “may be entering the terminal phase” is not intended to be restrictive to only those situations where death is imminent.

Background

20. Mr C had a diagnosis of cancer and several other long-term health conditions. He had a cancerous tumour on his left collarbone that was causing him pain and making breathing more difficult.
21. On 29 August 2023, Mr C suffered a fall at home and was complaining of chest pains. An ambulance transported Mr C to hospital, and he was admitted that evening. A doctor noted a conversation with Mr C’s family, writing that they discussed his overall presentation and the presence of malignant cancerous tumours around his spine, collarbone and kidney.
22. The clinical team met with Mrs B and her sister on 14 September. Mr C’s family felt they were not being kept updated about his care and were concerned they could not properly plan for his future. The notes show clinicians discussed Mr C’s prognosis and the fact his cancer was advanced and had spread to his bones and other organs. The notes record that “it was likely [Mr C] was approaching the last weeks/months of his life”.
23. On the same day, the clinical team concluded Mr C would not be suitable for any active cancer treatment due to his overall frailty.
24. Mrs B and her sister spoke to the discharge coordinator on 19 and 22 September. The family were unhappy about the possibility of Mr C being discharged with a package of reablement care due to previous bad experiences with the service. Mrs B said Mr C should not be discharged until any equipment and adaptations were in place for him at home.
25. On 22 September, the Trust completed a mental capacity assessment to determine whether Mr C had capacity to make decisions about his discharge destination. The assessment found Mr C did have capacity.
26. The Trust convened a meeting with the family on 27 September. The family expressed frustration about Mr C’s previous care. They also said they felt they had not been kept updated about his prognosis or discharge arrangements. The professionals present explained Mr C would not be suitable for the fast track CHC funding. Instead, hey explained Mr C would be discharged with a package of care and a referral to the community palliative care team.
27. On 29 September, the Trust made a referral for Mr C to the Council. A Council officer spoke to Mrs B. Mrs B advised that her mother had also been admitted to hospital and reported her concern that Mr C would be unable to cope at home on his own.
28. The Council arranged for Mr C to have a package of care to support at home on discharge. This involved four care visits per day. Mr C was discharged that day.
29. Mrs B contacted the Council on 2 October. She said Mr C had still not received a hospital bed, despite having been promised one when he was still an inpatient. Mrs B said she felt Mr C also needed a riser recliner chair as he was slipping down in his own chair.
30. The Council officer emailed the district nursing service to arrange an assessment for a hospital bed. The officer also referred Mr C to the Occupational Therapy (OT) service for assessment for a riser recliner chair.
31. A social worker contacted Mrs B on 9 October. They discussed Mrs B’s concerns about the handling of Mr C’s discharge. Mrs B said Mr C had not been referred to the palliative care team and had been discharged without the medication he needed.
32. The social worker assessed Mr C on 13 October. The assessment found Mr C would require support on a long-term basis. The social worker arranged an increased care package involving four visits per day. The social worker noted Mr C was under the care of the palliative team. The social worker also recorded that Mr C “has not been fast tracked but his prognosis is less than a year.”
33. On 23 October, the Council completed a CHC checklist for Mr C. Subsequently, on 3 November, the local ICB found Mr C to be suitable for the CHC fast track pathway. At that point, the ICB assumed responsibility for Mr C’s care.

Analysis and findings

Hospital discharge - Fast track pathway

34. One key consideration that formed part of the planning for Mr C’s discharge was whether he was suitable for the CHC fast track pathway. This process is intended to identify whether an individual needs quick access to CHC and ensure appropriate funding and care arrangements are put in place without delay. The CHC Framework says it is the ‘appropriate clinician’ that decides whether a person is suitable for this pathway. In Mr C’s case, this would have been the clinical team responsible for his care as an inpatient.
35. The CHC Framework says that the process should be “carefully and sensitively explained to the individual and (where appropriate) their representative. Careful decision-making is essential in order to avoid the undue distress that might result from changes in NHS Continuing Healthcare eligibility within a very short period of time.”
36. On 19 September, the discharge coordinator met with Mrs B. The discharge coordinator explained that Mr C was due to be reviewed by the palliative care team and that further decisions could then be made about Mr C’s discharge arrangements.
37. The palliative care review took place on 20 September. The palliative care team noted that Mr C likely had less than a year to live and that “as such would not fulfil FT criteria". No further rationale was recorded.
38. The discharge coordinator discussed the matter with Mrs B again at a further meeting on 27 September. The discharge coordinator noted “Family kept trying to push for [fast track package of care]…reminded [Mr C] does not meet [fast track] criteria as of today.” Mrs B said she had been told by a doctor that Mr C did meet the criteria. However, the discharge coordinator reiterated that he did not.
39. This was ultimately a decision for Mr C’s appropriate clinician. Nevertheless, I would expect to see a clearly recorded rationale for this decision in the clinical records. This in turn allows for clear communication with the patient and their family.
40. The CHC Framework is clear that terms such as “rapidly deteriorating” or “entering the terminal phase” should not be interpreted narrowly. For this reason, the estimated length of time Mr C had left to live did not, in itself, adequately explain the decision that he was not suitable for the fast track pathway.
41. It is important to be clear that it is not for the Ombudsmen to decide whether a person is suitable for the fast track pathway. However, the failure to adequately record and explain this decision was contrary to the requirements of the CHC Framework and represents fault by the Trust.
42. This caused Mrs B unnecessary confusion and frustration. This was evident from the note of Mrs B’s conversation with the discharge coordinator on 27 September. This was exacerbated when Mr C was subsequently placed on the fast track pathway in early November. I have addressed this in the ‘Action’ section of this decision statement.
43. Further confusion appears to have arisen surrounding Mr C’s prognosis. The clinical records show the family was keen to have a full understanding of Mr C’s condition.
44. The family spoke to the discharge team on 19 September to explain that they were still waiting for the outcome of a multidisciplinary team meeting the previous week. The discharge coordinator noted a plan to have a senior doctor speak to Mr C’s family about his care.
45. This was discussed again on discharge meetings on 22 and 27 September. By this point, no senior clinician had spoken to the family and the outcome of multidisciplinary team discussions remained outstanding. I found no evidence of any further discussion with Mr C’s family about his prognosis prior to his discharge on 29 September. This was further evidence of fault by the Trust.
46. This caused Mrs B further avoidable confusion and frustration.
47. In its response to Mrs B’s complaint, the Trust acknowledged communication on the ward had been poor and apologised for this. It said it has now introduced additional senior nurses to provide oversight and support to ward matrons and managers.
48. The Trust said it had launched a new programme entitled ‘Focus on Fundamentals’ to improve key aspects of care, such as doctor to patient/relative communication.
49. In its response to my enquiries, the Trust also shared a copy of its ‘Compassion in Care’ model, which it introduced in May 2024. This places communication as a central pillar of care and emphasizes the importance of listening to patients and their carers or relatives and addressing their concerns. The Trust confirmed staff have now received training on the implementation of this model.
50. I am satisfied the initiatives the Trust has introduced will improve communication and reduce the risk of similar problems occurring in future.
51. However, I have made some additional recommendations in the ‘Action’ section of this decision statement.

Hospital discharge – Discharge arrangements

52. Mrs B complained that the Trust and Council discharged her father from hospital without a proper care plan in place and without any instructions for his GP. She said they failed to make appropriate referrals for Mr C to community services on discharge. In addition, Mrs B complained that the Trust discharged Mr C without the medication he needed.
53. The National Discharge Guidance introduces the expectation that a person will be discharged from hospital as soon as there is no clinical need to for them to remain a patient. This allows for further assessment of a person’s long-term care needs once they have been discharged into the community.
54. In Mr C’s case, as explained above, the discharge team concluded Mr C did not have a primary health need. As a result, the discharge team made a referral to the Council. The Council arranged a package of four daily care visits to commence on Mr C’s discharge. These visits were intended to support Mr C with various activities of daily living, including personal care, preparing meals and medication supervision. There was a basic care plan in place for Mr C at the point of discharge, therefore.
55. A social worker then visited Mr C at home on 13 October to complete an assessment and draw up a full care and support plan. This was in completed later that month. I am satisfied the Council assessed Mr C’s social care needs appropriately and put a care plan in place for him, albeit responsibility for his care transferred to the local ICB shortly afterwards. I find no fault by the Council in this matter.
56. Nevertheless, there is evidence of errors and omissions on the part of the Trust in its handling of the discharge.
57. The discharge team’s notes for 29 September, the day of Mr C’s discharge, record that referrals would need to be made for Mr C to the district nursing service (for catheter care) and the Community Palliative Care Team.
58. The evidence I have seen suggests the discharge team did make the referral to the district nurses. However, the discharge summary Mr C’s GP received from the hospital made no mention of his need for a palliative care referral. As a result, Mrs B had to contact the GP herself to arrange the referral.
59. There were further errors with Mr C’s medication. The discharge summary records that Mr C had been prescribed opioid medication and paracetamol to treat his severe pain. Despite this, he was discharged only with paracetamol. Again, Mrs B was required to arrange a prescription for the correct medication through Mr C’s GP.
60. These errors represent further evidence of fault on the part of the Trust. This meant Mr C was left in avoidable pain until Mrs B could arrange a prescription. This in turn caused her further distress.
61. In summary, there is evidence of confusion and omissions surrounding the discharge that caused Mrs B distress at what was a very difficult time. This also meant Mr C was discharged without appropriate palliative care in place.

Subsequent care

62. In her complaint to the Ombudsmen, Mrs B said the carers who supported Mr C following his discharge were inadequately trained and inexperienced.
63. I have reviewed the records for the period from the commencement of the care package until responsibility for Mr C’s care package passed to the ICB in early November. I found no evidence of poor care in the relatively limited records available, nor any suggestion that the family had raised concerns about the standard of care.
64. I also reviewed the Council’s records for the same period. These show Mrs B contacted the Council several times to request equipment (such as a hospital bed and riser recliner chair) for Mr C. However, I found no evidence to suggest Mrs B raised any concerns about the quality of care Mr C was receiving from the care visitors at that time.
65. I accept the poor handling of Mr C’s discharge from hospital more generally caused Mrs B great distress and frustration at a difficult time. However, based on the limited evidence available to me, I found no basis on which to make a finding of fault by the Council (on whose behalf the care agency was acting) on this point.

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Action

66. Within one month of my final decision statement, the Trust will write to Mrs B to apologise for the distress, frustration and confusion caused to her by its failure:

• to properly record and explain the decision that Mr C was not suitable for the CHC fast track pathway;
• to arrange for a senior clinician to meet or speak with the family to explain his prognosis and address their questions about his care;
• to make a referral for Mr C to the Community Palliative Care team, or request that his GP did so; and
• to discharge Mr C without the medication he required.

67. The Trust will also pay Mrs B £500 in recognition of the impact of these events on her.
68. Within three months of my final decision statement, the Trust will explain what action it has taken, or will take, to:

• to ensure clinical staff are aware of the need to properly record and explain CHC fast track decisions in keeping with the requirements of the CHC Framework;
• to ensure staff use a patient’s discharge summary to properly record information about their ongoing care needs, including any medication or community referrals they require, and provide clear instructions for any community services; and
• to ensure patients are discharged with any appropriate medication and equipment and that any onward referrals for care in the community have been completed.

69. The Trust will also provide the Ombudsmen with more information about the ‘Focus on Fundamentals’ programme, detailing any specific actions completed as part of this programme of improvements.
70. The Trust will provide us with evidence it has complied with the above actions.

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Decision

71. I found fault by the Trust that resulted in an injustice to Mrs B. The Trust will now take the above actions to remedy this injustice.
72. I found no fault on the part of the Council with regards to its involvement in Mr C’s care.

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Investigator's decision on behalf of the Ombudsman