Summary: We uphold Mr X’s complaint about his unsafe hospital discharge. We found the Trust and Council failed put a package of care in place for Mr X prior to his discharge from hospital. We also found fault with the way the Care Provider communicated with Mrs Y. The Council and the Trust will apologise to Mr X and Mrs Y and take action to prevent similar problems occurring in the future.

The complaint

1. Mrs Y complains on behalf of her brother, Mr X, about the failure of Lancashire County Council (the Council) and Lancashire Teaching Hospital NHS Trust (the Trust) to put an appropriate care package in place for Mr X prior to his discharge from hospital in March 2022.
2. Mrs Y complains that Flexecare (the Care Provider), commissioned by the Council, cancelled Mr X’s care package without sufficient communication or notice. She also complains that the Care Provider’s complaint response contained incorrect information.
3. As a result, Mrs Y says Mr X was left without care when he arrived home from hospital. She says his care and wellbeing has been affected. Mrs Y says these events also caused her a great deal of stress and inconvenience.
4. Mrs Y and Mr X would like a recognition of fault and an apology.

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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. 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

8. I discussed the complaint with Mrs Y, Mr X’s sister, who is supporting Mr X with his complaint. I reviewed information provided by the Trust and the Council including the responses to my enquiry questions, Mr X’s hospital records and the Care Provider’s daily notes. In addition, I took account of the relevant guidance and legislation. I have carefully considered all the written and oral evidence submitted to us, even if we do not mention specific pieces of evidence within the decision statement.
9. I shared the draft decision with Mr X and Mrs Y, the Council and the Trust and they had an opportunity to comment. I have carefully considered the comments I received.

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What I found

Key legislation and guidance

Hospital Discharge

10. Department of Health guidance: Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate care (March 2010) (the ‘Ready to go guidance’) is the core guidance around hospital discharge. It contains ten operating principles for staff to follow during discharge planning, including:

• discharge and transfer planning starts early to anticipate problems, put appropriate support in place and agree an expected discharge date,
• the care planning process is co-ordinated effectively
• communication creates strong and productive relationships between practitioners, patient and carers.
• The multidisciplinary team works collaboratively to plan care, agree who is responsible for specific actions and make decisions on the process and timing of discharges and transfers.

What happened

11. In January 2022, Mr X began to receive a care package of three daily visits from the Care Provider.
12. From mid-February 2022 onwards, Care Provider staff started to raise concerns about incidents of inappropriate behaviour by Mr X.
13. On 17 March 2022, the Care Provider held a review meeting with Mr X and Mrs Y to discuss his behaviour towards staff. Mrs Y advised the Care Provider that Mr X’s social worker was on leave for two weeks and asked that care be provided at least until the social worker returned. The Care Provider agreed to monitor Mr X’s behaviour over the next two weeks.
14. On 20 March, Mr X was admitted to Preston Royal Hospital with chest pains and shortness of breath. He was diagnosed with pneumonia and remained in hospital for ten days.
15. On 30 March, Mr X was deemed medically fit for discharge. Mrs Y spoke with the Care Provider’s care supervisor and asked for Mr X’s care package to be reinstated. Mrs Y says the Care Provider told her that care visits would resume around teatime that day.
16. Mrs Y then spoke with the hospital’s discharge facilitator and confirmed that Mr X’s care visits would resume that evening. The discharge facilitator told the ward nurse that Mr X’s care package was arranged to restart and the discharge process could begin. The discharge facilitator did not contact the Care Provider to confirm that it could still provide Mr X’s care package.
17. Following the telephone call with Mrs Y, the care supervisor discussed Mr X’s care package with the Care Provider manager. The Care Provider decided that it was no longer able to meet Mr X’s needs and therefore could not facilitate his care package.
18. The Care Provider says the care supervisor rang the hospital ward to advise that it could not provide care to Mr X. According to the Care Provider records, during this conversation a ward nurse said that she would pass the information on to the discharge team. However, the Care Provider did not record which nurse the care supervisor spoke to. The Trust has no record of this call.
19. The Care Provider did not phone Mrs Y back to tell her that it would not be providing Mr X with care.
20. Mr X was discharged home later that afternoon. When no carers had arrived by 9pm, Mrs Y phoned the Care Provider and was told that no care package was in place.
21. On 31 March, the Care Provider contacted the hospital ward by telephone and spoke with a nurse about what had happened. The nurse apologised that the Care Provider’s message from the previous day had not been passed on or recorded.
22. The ward nurse, the Care Provider and Mrs Y all contacted the Council to try and arrange crisis care for Mr X. A crisis care package of one call a day was put in place later that evening. This arrangement continued long term.

Analysis

Mr X’s discharge from hospital

Failure to ensure care package was in place prior to discharge

23. Mrs Y complains that Mr X was discharged home without a care package in place. She says he is a vulnerable person and failure to provide care left him at risk and caused her significant stress.
24. In response to my enquiries, both the Trust and the Council confirmed that the usual process would have been for the discharge facilitator to contact the Care Provider to confirm whether it could provide Mr X’s care package and when care visits would commence. This did not happen. Instead, the discharge facilitator accepted the information provided by Mrs Y, without seeking confirmation directly from the Care Provider. This incorrect information was then passed on to the ward nurse, who proceeded to arrange discharge. This is fault.
25. The Care Provider said it rang the hospital ward to advise that it was unable to provide a care package to Mr X. The Trust has no record of this phone call and there is no evidence to suggest any action by hospital staff following receipt of this information. Due to the lack of records by the Trust, Mrs Y is doubtful that this call took place.
26. I have considered her concerns and reviewed the Care Provider’s electronic daily records and a written statement from the care supervisor, which both record the phone call to the hospital on 30 March. The phone call is referenced again in both the Care Provider and the Trust’s records for 31 March, when the Care Provider contacted the hospital ward to discuss the incident. From the evidence I have seen, I am satisfied that, on the balance of probabilities, the Care Provider contacted the hospital ward on 30 March to advise it would not restart Mr X’s care package. There is fault by the Trust for failing to record this information, pass it on to the discharge team or take any other action with it.
27. Had either of these steps been handled properly, then the discharge team would have been aware that Mr X did not have a care package in place. The discharge facilitator could then have taken the appropriate steps to arrange for a new care package to be put in place prior to discharge.
28. Overall, communication was poor and the actions of the hospital discharge team and ward staff were not in line with the Ready to go guidance. These combined failures led to Mr X being unsafely discharged home without a care package. This left Mr X at risk overnight on 30 March and caused Mrs Y significant stress and worry.

Actions of the Care Provider

Mrs Y’s phone call with the Care Provider

29. Mrs Y complains that the Care Provider confirmed to her during a telephone call that Mr X’s care visits would restart at teatime on 30 March. She complains that the Care Provider then changed its mind about providing care but did not tell her. She says the care supervisor said she would let her know if there were any problems.
30. I have checked the Care Provider’s electronic records and the care supervisor’s statements. Both record the care supervisor advising Mrs Y that “if [my emphasis] the care package was restarted, the first visit would be around teatime that day”. The care supervisor records that she told Mrs Y to “leave it with her” and did not confirm that the care package would be restarted.
31. Mrs Y strongly disagrees with the Care Provider’s account, saying the care supervisor did not use the word “if”.
32. The contents of this phone call are disputed and there is no independent source, such as an audio recording, to verify either account. As such, I am unable to make a finding about whether the Care Provider advised Mrs Y that the care package would restart that evening.
33. However, the Care Provider’s failure to call Mrs Y back and tell her that it would not be providing care further exacerbated the situation.
34. The Council Contracts Team has explained that, as the Council was the care commissioner, the Care Provider was only required to notify the Council of a decision to cancel a care package.
35. Nevertheless, Mrs Y had spoken to the care supervisor earlier that day and had a clear expectation that the existing care package would continue at least until the social worker returned from leave. Therefore, it is reasonable that she would have also expected to have been told of any problems. The Care Provider should have updated Mrs Y, regardless of its technical obligations. This communication failing is fault and caused unnecessary confusion and upset for Mrs Y.
36. As part of my enquiries, both the Trust and the Council accepted it would have been prudent and courteous for the care supervisor to update Mrs Y in the circumstances. The Care Provider also accepted this in their complaint response and apologised to Mrs Y.

Care Provider’s decision

37. Mrs Y is particularly unhappy with the Care Provider’s decision not to restart the care package. She feels the Care Provider broke the agreement to monitor Mr X’s behaviour for two weeks and to not end the care package while his social worker was on leave. She also says the Care Provider failed to give the required seven days’ notice period.
38. While I understand Mrs Y’s concerns, ultimately the previous discussions and agreements around monitoring Mr X’s behaviour has limited relevance. This is because the length of time Mr X was admitted to hospital superseded these prior arrangements.
39. In response to my enquiries, the Council explained that when a person is admitted to hospital, their care package is kept open with the care provider as standard for seven days. This is to allow the package to be restarted on discharge. However, where a hospital admission exceeds this timeframe, as was the case for Mr X, the care package would then be automatically suspended. Once a person is ready for discharge, the hospital discharge team would usually refer the person for a new package of care. This may involve contacting the previous care provider to see if it can reinstate the care package, however care providers are not obliged to do so.
40. The Council said that, due to high demand for care services, it is not unusual for care providers to accept new referrals after the seven-day timeframe to fill the available slots. In these circumstances, a care package would usually be ended by the Care Provider contacting the Council and/or the discharge facilitator contacting the Council at the point of discharge when it had been established that the previous care provider no longer had capacity.
41. Mr X was in hospital for ten days. Therefore, the Care Provider was not required to formally serve notice in these circumstances as the care package had already automatically ceased after Mr X had been in hospital for seven days. This also means that the Care Provider did not technically withdraw the care package.
42. Further, by the point Mr X was fit for discharge, the Care Provider was not obliged to reinstate Mr X’s care package due to the time passed.
43. The Care Provider was aware that the social worker was on leave at the time and that Mrs Y had requested no changes to the care package while the social worker was away. However, any potential impact of this was mitigated by the fact that Mr X was safe in hospital and had access to the discharge team who were able to organise alternative care arrangements for him (although I acknowledge this did not happen).
44. While the Care Provider’s communication with Mrs Y should have been better, I have not found fault with their decision to decline to provide further care.

Care Provider’s complaint handling

45. Mrs Y complains that the Care Provider has refused to accept fault for their actions. She also says their complaint response contained factual inaccuracies.
46. In the Care Provider’s complaint response, it accepts that the care supervisor should have returned Mrs Y’s call and apologises for that. The Care Provider explains that it contacted the hospital to advise that it could no longer facilitate Mr X’s care package and the discharge facilitator did not make contact to discuss the care package. Its position is in line with the findings I have made above.
47. As a result of Mrs Y’s complaint, the Care Provider has also reviewed its policy for withdrawing care packages and made improvements, including clear reference to the need to consult all parties including the social worker and family members. Overall, I have not found fault with the Care Provider’s findings. I am also satisfied that it has taken sufficient steps to put things right by apologising to Mrs Y for lack of communication and reviewing its policies.
48. However, there is a factual inaccuracy in the complaint response which says the hospital told the Care Provider that no discharge facilitator was available on 30 March and therefore the discharge had been handled by a ward nurse.
49. Mrs Y called the ward on 22 April 2022 to discuss, although the Trust have no record of this phone call. She says she was advised that a discharge facilitator was available on 30 March. Mrs Y feels that the Care Provider has “lied” to her and does not believe their account of events on 30 March.
50. As part of my enquiries, the Trust confirmed that the discharge facilitator was available on 30 March.
51. I have also reviewed the Care Provider’s notes of their telephone conversation with the ward nurse on 31 March. It records the nurse apologising that the message was not passed on and that there was no discharge facilitator available that day so she would take steps to try and arrange crisis care for Mr X.
52. The nurse’s reference to there being no discharge facilitator available relates to the 31 March, not 30 March. Unfortunately, the Care Provider’s complaint response misinterpreted this and provided incorrect information in its response. I acknowledge that this has caused mistrust and significant frustration for Mrs Y, however I do not consider this error amounts to fault.

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Agreed actions

Council

53. Within one month of my final decision statement, the Council will:

• apologise to Mr X and Mrs Y for failing to ensure that Mr X had a care package in place prior to his discharge.

Trust

54. Within one month of my final decision statement, the Trust will:

• apologise to Mr X and Mrs Y for failing to ensure that Mr X had a care package in place prior to his discharge; and
• review processes to ensure that telephone calls to the hospital ward are properly recorded and passed on as appropriate.

Trust and Council

55. Within one month the Trust and the Council will write to the Ombudsmen to confirm that they have

• reviewed their discharge policies and guidance to ensure sufficient communication with patients, family members and care providers, then ensure this is communicated to the relevant staff members.

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Final decision

56. I found fault with the way the Council and the Trust handled Mr X’s discharge. As a result, Mr X was discharged without a care package in place. I also found fault with the way the Care Provider communicated with Mrs Y, however it has taken reasonable steps to put things right.
57. I am satisfied the actions the Council and the Trust have agreed to take represent a reasonable and proportionate remedy for the injustice caused to Mr X and Mrs Y by the fault I have identified. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman