Summary: Mr A has complained about the actions of a Trust and Council in relation to his mother’s discharge from hospital. I find fault with the Trust and Council’s actions and they have agreed with my recommendations to provide a remedy to Mr A.

The complaint

1. Mr A complains on behalf of his mother, Mrs B, about Dudley Metropolitan Borough Council (the Council) and The Dudley Group NHS Foundation Trust (the Trust), relating to her hospital discharge in June 2021. Specifically, Mr A complains the Trust and Council:

• blocked his mother’s discharge; and

• failed to provide intermediate care services.

2. Mr A said this led to his mother being denied care services, unnecessary financial expense, and undue stress.
3. As a result of this complaint Mr A would like reimbursement for privately funded care, staff training, a policy and procedure review, an apology and improvements in social care.

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The Ombudsmen’s role and powers

4. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)
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. 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)
8. 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 that the relevant responsible body has to make. Therefore, my investigation has focused on the way that the organisations made their decisions.

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How I considered this complaint

9. During this investigation I have considered evidence from Mr A, the Council and the Trust. I have also considered the relevant guidance and legislation. I gave giving Mr A, the Council and the Trust the opportunity to comment on my draft decision. I considered Mr A’s comments before making this final decision.

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What I found

Background

10. In 2021 Mrs B was in her 80s and lived at home. She had carers who came in and helped her with daily activities. She had Parkinson’s disease and was admitted to hospital with vomiting and feeling unwell. She remained in hospital for several days before she was discharged back to her home.
11. Mr A was unhappy with matters surrounding his mother’s discharge at the time and made a complaint which was responded to by the Council and the Trust before he approached the Ombudsmen in November 2021.

Discharge

12. Mr A said on the day his mother was due to be discharged the discharge was blocked by the Council. He said this was in relation to the possibility of his mother having a pressure sore and this needing to be assessed to see if it would affect her care plan. Pressure sores are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. They can happen to anyone, but usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time. Moving and regularly changing a person’s position can improve the condition of a pressure sore or prevent it getting worse.
13. Mr A said the supposed pressure sore was actually a water lesion, not a pressure sore, and did not require further long term support. A moisture lesion is soreness and blistering where the skin has been exposed to wetness over a long period of time.
14. He complained about the Trust and Council blocking his mother’s discharge and keeping her in the hospital against her wishes. He said this led to increased exposure to COVID-19 infection.
15. The Council said the delay in discharge was due to waiting for a tissue viability report to assess Mrs B’s pressure sore. Once this was done Mrs B was discharged with a package of care which included the need for carers to turn Mrs B every two hours.
16. The Council said it explained to Mr A that due to the pressure sores and his mother being assessed as requiring two or three hourly turns at night the Council had to await an update from the Trust as to what level of care was required in the community to ensure a safe discharge.
17. In addition, the Council said Mrs B’s current care agency was withdrawing its care and another one had to be found. Mrs B was discharged the day after the tissue viability report was completed, a day later than the day Mr A had expected it to happen.
18. The Trust said the Council contacted its discharge team and said it could not discharge Mrs B until extra care calls were put in place for when she returned home. These care calls related to the need for Mrs B to be turned every two hours to manage her pressure sore.

Analysis

19. From the evidence of the hospital records it is clear Mrs B did have a pressure sore when she was discharged from hospital.
20. The National Institute for Health and Clinical Excellence (NICE) guidance - ‘Pressure ulcers: prevention and management’ clinical guideline (CG179]) recommends all pressure sores be measured and categorised in relation to grading on how serious they are. It also recommends regular repositioning for those at risk of pressure sores.
21. Taking this into account it was reasonable for discharge to be delayed for a few days while the Trust assessed Mrs B’s pressure sore and the treatment it required. This meant her pressure sore could be appropriately managed when she left hospital. In addition, the Council was correct in making sure Mrs B had sufficient support in place for when she left hospital before she was discharged. Therefore, I have not found fault with the Council or Trust on this aspect of the complaint.

Lack of intermediate care

22. Mr A complained that after his mother was discharged, the care provided should have been classed as ‘intermediate care’ which would have been free. He said the failure to provide this was in breach of the Care and Support (Charging and assessment of resources) Regulations 2014, section 3. This section says a Council should not charge for care that is intermediate care and reablement support services for the first six weeks of a specified period. It goes on to say that the purpose of these support services is provision of assistance to enable a person to maintain or regain the ability needed to live independently in their own home.
23. Mr A said that because the new care package had the increased need of his mother having to be turned every two hours, he had to pay extra in private care fees and these should have been free for at least six weeks.
24. The Council said intermediate care and reablement is designed to reduce or extinguish existing needs for care and support after discharge from hospital.
25. The Council said a Trusted Assessor who helped with the discharge and a physiotherapist stated Mrs B would not benefit from the therapy service in view of being cared for from bed for the last six months. A Trusted Assessor is someone acting on behalf of and with the permission of a provider (in this case the Council and the Trust), to facilitate speedy and safe transfer from an acute hospital to a community or residential setting.
26. The Council went on to say intermediate care or more reablement provisions would not have helped Mrs B regain any more independence than her preadmission condition.
27. The Council said the plan was to care for Mrs B in bed with two care staff in attendance to ensure she could complete daily living activities safely and that she was repositioned in bed.
28. The Council said there were concerns on the ward about pressure sores so district nurses would oversee treatment by daily cleaning, applying ointment and dressing to ensure this pressure sore wound was properly managed and Mrs B remained comfortable.

Analysis

29. Intermediate care is a multidisciplinary service that helps people to be as independent as possible. It provides support and rehabilitation to people at risk of hospital admission or who have been in hospital. It aims to ensure people transfer from hospital to the community in a timely way and to prevent unnecessary admissions to hospitals and residential care.
30. There is evidence in the hospital records that Mrs B had been bed bound prior to her admission. Therefore, the hospital’s assessment that she was not suitable for reablement or intermediate care was reasonable as there was little potential for her to regain independence.
31. In addition, I have not found fault with the Council for not putting Mrs B on intermediate care as it was informed by the assessments while she was still in hospital and found to be unsuitable for this type of care.
32. However, there was a national Hospital Discharge and Service Policy and Operating Model (the Operating Model) in effect at this time. This was to encourage patients to be discharged from hospital at the earliest opportunity due to COVID-19 concerns. It allowed for additional needs which were not in effect before admission to be met for free following discharge. This would be for up to six weeks or until their needs are properly assessed or the needs are no longer in effect.
33. In this instance, the Council carried out a Care Act Assessment of Mrs B in July 2021 after being discharged in June 2021. Under the Operating Model, the extra service of Mrs B being turned every two hours should have been free until her assessment in July 2021. The Operating Model states that on decision of discharge the person or their carer should be informed of this arrangement and receive a leaflet explaining it. There is no evidence the Trust did this. Therefore, there was fault in the Trust not letting Mr A know about this service.
34. There is a complicating factor in that the Council offered Mr A for his mother to have a Care Act Assessment whilst she was in hospital, but Mr A declined it. Section 11 of the Care Act states that this assessment should still be carried out if the Council felt if Mrs B lacked capacity, but it was in her best interests. In addition, Mrs B had been assessed as having capacity just a couple of days beforehand and so it is unclear why Mr A could decline a Care Act assessment on her behalf.
35. In this case there is no evidence the Council offered Mrs B an assessment or considered whether she lacked capacity and, if so, whether the lack of assessment was in her best interests. This was a fault on its part. The Council then did not carry out a Care Act assessment until July 2021.
36. The fault by the Trust of not informing Mr A and/or Mrs B of her entitlements under the Operating Model and the delay in a Care Act assessment by the Council led to uncertainty for Mr A on who would pay for his mother’s additional care and to him having to pay for it.

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Recommendations

37. Due to the faults I have outlined and the impact they had on Mr A and his mother I recommend that by 2 August 2022 the Council and Trust should:

• write to Mr A acknowledging and apologising the impact the faults in the lack of information and lack of assessment had on him and his mother; and
• work together to establish the additional care costs Mr A paid; and
• within a month of establishing the additional care costs, reimburse Mr A with costs being split 50/50 between the Council and the Trust.

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Final decision

38. I find fault with the Council and Trust in relation to the lack of provision of free care to meet Mrs B’s additional needs after she was discharged. I do not find fault with the other aspects of this complaint.

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Investigator's decision on behalf of the Ombudsman