Summary: Mr F complained about the way the Council and the Trust dealt with his late father’s discharge from hospital and arranged a homecare agency to start support. He also complained about the loss of his father’s jewellery when he was admitted to hospital in December 2020. We found fault in the way the Council arranged homecare support as Mr F’s father was left without support on the day of his discharge. This caused Mr F avoidable distress. The Trust did not ensure a property list was completed when Mr F’s father went into hospital. Because of this Mr F is left with uncertainty about what happened to his father’s jewellery. The Council and the Trust have agreed to our recommendations and will apologise to Mr F and improve. The Council and the Trust will also make symbolic payments to acknowledge the injustice caused to Mr F.

The complaint

1. The complainant, who I shall refer to as Mr F, complains about the way Trafford Council (the Council) and Manchester University Hospitals NHS Foundation Trust (the Trust) dealt with his late father’s, Mr G, discharge from hospital in
   December 2020. Mr F says the Council and the Trust did not ensure a homecare agency (the care provider) was in place on the date his father was discharged. Because of this he says his father was without pain relief medication for several hours and this had adverse impact on his health and wellbeing resulting in his readmission to hospital the next day. He also says the Trust failed to protect his father’s jewellery when he was admitted to hospital and as a result his father’s gold chain and silver cross went missing and cannot be accounted for. To put things right Mr F seeks a financial remedy to acknowledge the impact the alleged faults had on his late father and him. He also feels the Council and the Trust should improve their procedures.

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The Ombudsmen’s role and powers

2. The Ombudsmen will not generally investigate a complaint unless they are satisfied the matter has been brought to the relevant organisation’s attention and that organisation has had a reasonable opportunity to investigate and reply to the complaint. (Local Government Act 1974 section 26(5), as amended and Health Service Commissioners Act 1993, section 9(5))
3. However, in the case of joint complaints (i.e. those deemed suitable for investigation by the Joint Working Team operated by both PHSO and LGSCO), if one organisation has investigated and replied to the complaint but another organisation has not, the Ombudsmen may decide to exercise their discretion to investigation the complaint against both (or all) organisations, so that the issues can be considered in the round.
4. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
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 have considered information provided by the complainant. I have also considered information from the Council and the NHS Trust’s responses to this complaint. I have also considered the law and guidance relevant to this complaint.
9. Mr F did not complain to the Council about the events complained about. I have exercised discretion to consider his complaint about the Council as the same time as the Trust as events regarding the discharge arrangements are entwined.
10. All parties had an opportunity to respond to a draft of this decision.

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What I found

Background

11. Mr G lived at home on his own in the community and in November 2020 he fell down the stairs and was admitted to hospital. The result of his assessment in hospital concluded he had a fracture to his lower spine.
12. The Council said on 1 December 2020 it received a referral from the Integrated Discharge Team to arrange a commissioned homecare package when Mr G was ready for discharge. It said the referral also contained a request for a falls pendant and a key safe.
13. A homecare agency, Agency X, expressed an interest in providing the homecare package. Mr G’s discharge from hospital was delayed because he had close contact with a person who had the virus known as Covid-19, so he was not medically fit for discharge.
14. The Trust said it sent the discharge to assess paperwork to the Council on
    10 December. The Council said the referral was incomplete as it did not contain any information on Mr G’s Covid status. The Trust resent the complete referral on 11 December.
15. The Trust said the officer working on behalf of the Council confirmed Agency X could start providing care and support from lunchtime on 16 December when
    Mr G was discharged from hospital. The care and support plan included assisting Mr G with his medication such as pain relief.
16. Mr F was present when his father returned home at 12.30 on 16 December and said the ambulance team told him Agency X would visit between 12.30 and 14.00 that day. Mr F said he spoke to his father around 17:00 by telephone and he told him Agency X had not arrived to provide the support call.
17. Mr F immediately contacted the Trust and spoke to the hospital ward where his father had been discharged from. He said he was told Agency X would be there soon. Mr F said Agency X did not arrive until around 20:30. The carer from Agency X told him it was scheduled to start the next day which is why nobody had come at lunchtime.
18. The carer from Agency X had concerns about Mr G’s health condition shortly after arriving at the property. Mr F said the ambulance did not arrive until 02.30 and his father was readmitted to hospital. He remained in hospital for about two weeks and was then discharged to a care home in January 2021. He passed away in March 2021.
19. Mr F complained to the Trust in March 2021 about the events surrounding his father’s discharge from hospital. He also complained about his father’s gold necklace going missing during his second admission to hospital. The Trust provided a response in April and a further response in June. Mr F then asked the Ombudsmen to consider a complaint.

Findings

How the Council and the Trust dealt with Mr G’s discharge from hospital

20. In response to our enquiries the Council said Agency X told it that it did not receive the homecare referral and access information for Mr G’s property when it agreed to provide care on 15 December 2020. The Council said it cannot provide evidence to show Agency X received clear confirmation the homecare should have started on 16 December at lunchtime.
21. The Trust said the commissioning officer from the Council emailed its staff to confirm Agency X would be starting the homecare support on 16 December. Because of this it discharged Mr G home expecting Agency X to arrive at lunchtime. The Trust acted on the information it had received from the Council.
22. The evidence available strongly suggests the Council did not send the information to Agency X it needed to start the homecare support on 16 December when Mr G was discharged from hospital. This is fault by the Council which led to Mr G being left at home alone for several hours without the care and support in place he was assessed as needing such as help to take his pain relief medication. This is likely to have caused injustice to Mr G but because he has died the Ombudsmen cannot now remedy any injustice caused to him.
23. Mr F said he remained outside his father’s home for several hours while waiting for the care agency and the ambulance because he could not enter without personal protection equipment due to the pandemic at the time. He said his father was in pain and suffering and this was an upsetting situation. Fault by the Council is likely to have caused Mr F avoidable distress.

How the Trust responded to Mr G’s missing jewellery

24. The Trust said it did not complete documentation which would have shown whether Mr G came into hospital wearing jewellery when he was readmitted in December 2020. It did not complete a property list when Mr G was admitted to the ward. Because the property list was not completed it could not say whether Mr G had the gold chain when he went onto the ward. This is fault by the Trust.
25. The Trust said it has reminded its staff about the importance of completing the property list on admission. It also said it had introduced a new property list for staff to complete with compliance monitored by its senior nursing team. The Trust acknowledged that it could not explain what had happened to Mr F’s father’s jewellery and apologised for the frustration and distress it caused. It is not necessary to ask the Trust to apologise again or improve.
26. The Trust said it would consider reimbursing the value of the jewellery if Mr F could provide receipts. Mr F does not have receipts for his late father’s jewellery and therefore could not respond to the Trust’s offer.
27. The Trust had a process in place to account for patients’ property when admitted to hospital. In Mr G’s case the staff did not complete the property list, and this is fault. The Trust apologised and improved its practice. Mr F could not provide receipts to the Trust due to the length of time his father had owned the jewellery. However, Mr F is still left with uncertainty about what happened to his father’s jewellery in particular his gold necklace.

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Agreed recommendations

28. The Council and the Trust have agreed to our recommendations and within four weeks of our final decision:
• the Council will apologise in writing to Mr F for the avoidable distress he experienced when his late father was left without care and support for several hours because of the failure to ensure the homecare agency was in place;
• the Council will pay Mr F £150 to acknowledge the avoidable distress he experienced;
• the Council will remind its officers of the importance of sending information to homecare agencies they need to start support calls and the importance of checking all information has been received by homecare agencies; and
• the Trust will pay Mr F £150 to acknowledge the uncertainty he experiences because of the failure of its staff to complete the property list.

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Final decision

I have found fault by the Council and the Trust and uphold Mr F’s complaint. The Council and the Trust have agreed to our recommendations, so I have completed the investigation.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman