London Borough of Croydon (18 010 646)

Category : Adult care services > Other

Decision : Upheld

Decision date : 22 Jan 2020

The Ombudsman's final decision:

Summary: The Ombudsmen found fault with a Hospital Trust’s communication with a patient’s family about discharge arrangements. However, there was no fault with the decisions to discharge the patient back to her own home or subsequently to a rehabilitation placement. The Ombudsmen also found fault by a Council not completing a carer visit for 15-hours after the patient returned home. This caused the patient and her family distress. The Council and the Trust have agreed to the Ombudsmen’s recommendations to ensure learning is taken from the complaint and ensure the faults do not happen again. They will also apologise to the complainant for the distress caused by the faults identified.

The complaint

  1. Mr T complains about London Borough of Croydon (the Council) and Croydon Health Services NHS Trust (the Trust). He complains about the care given to his late mother, Mrs G, at Croydon University Hospital and the discharge arrangements between April 2018 and June 2018.
  2. Mr T’s complains about the Trust’s communication with him. This related to his mother’s admission to hospital in April 2018, her fall two days later, and his mother’s discharge from hospital to her home and later, to a rehabilitation facility.
  3. Mr T also complains the Trust did not properly supervise his mother in hospital. He says the Trust did not adequately examine Mrs G after the fall and did not identify fractures to her elbow and hip for four days. Mr T says the hospital would not treat his mother’s fractured hip.
  4. Mr T says the Trust should not have discharged his mother to her home on 21 May 2018 as it was clear she was not fit for discharge. He also says the carer from the care agency (Supreme Care Services Ltd on behalf of the Council) did not visit his mother until the following morning, when they found his mother on the floor.
  5. Mr T says the failings in his mother’s care caused avoidable pain and distress to his mother. He says witnessing his mother’s distress and his concerns about her ability to cope at home after discharge also caused him distress and upset.
  6. Mr T says he incurred extra travel expenses because of having to attend meetings and make visits. He considers these were over and above what would have happened if there had not been failings in Mrs G’s care.

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The Ombudsmen’s role and powers

  1. 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)
  2. 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). 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.
  3. When considering complaints, if there is a conflict of evidence we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
  4. The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
  5. 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

  1. As part of my investigation of this complaint I have considered:
    • Information Mr T provided verbally and in writing
    • Written information from the Trust and Council
    • Relevant legislation and guidance

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What I found

Law and guidance

Falls in hospital

  1. The National Patient Safety Agency produced the Slips, trips and falls in hospital Report in February 2007. This aimed to improve understanding of the scale and impact of slips, trips and falls within the NHS, and to encourage staff at all levels to renew efforts to prevent falls. The report noted there will always be a risk of falls in hospital. It provided suggestions of what can be done to reduce the risk of falls while properly allowing patients freedom and the ability to mobilise during their admission.
  2. In June 2013 NICE issued the clinical guideline: Falls in older people: assessing risk and prevention (CG161). This notes that all patients over the age of 65 should be treated as at high risk of falling in hospital. The guidance says that staff should identify and address individual risk factors that can be treated or improved.
  3. Older people who present for medical attention because of a fall, or report of recurrent falls in the past year, should be offered an assessment with multiple components to identify a person’s risk factors for falling. If appropriate, an individualised intervention with multiple components that aims to address the risk factors for falling identified in a person's assessment should be considered.
  4. Moving and handling risk assessments help identify where injuries could occur and what to do to prevent them. They are mandatory requirements (Manual Handling Regulations 1992 as amended 2002) and local policy should reflect national legislation. The risk assessments are important not only for the safe handling of patients but also to ensure that the risks to nursing staff are minimised.

Privacy and Dignity

  1. The British Geriatric Society issued a good practice guide in 2006 (updated May 2018) - Dignity - supporting toilet access and use in frail older people. This says all people, whatever their age and physical ability, should be able to choose and use the toilet in private. It says people’s choice is paramount and that privacy and dignity must be preserved.

Mental Capacity Act

  1. 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.

Hospital discharge

  1. Leaving hospital after an inpatient stay is part of a process and not an isolated event. Planning should start at the earliest opportunity and it should involve health and social care staff in the hospital and community working together. The process should lead to a personalised plan for each patient who is leaving hospital. Good discharge planning should help patients leave hospital safely, without delay and with suitable support ready in the community. Key guidance about this is the Department of Health’s Ready to go? Planning the discharge and transfer of patients from hospital and intermediate care, published in 2010. I will refer to this as the ‘Ready to go guidance’.
  2. The Trust’s Discharge Planning Policy (paragraph 4.27) says it aims to discharge patients early in the day. This is to allow time for clear communication between the ward and care providers or family regarding care needs and future support plans, and for settling in at the chosen destination.
  3. Paragraph 4.6 of the policy says it should be clearly identified who else the patient wishes to be informed and/or involved in the discussions and decisions regarding discharge. It also notes the patient, their family, carer or advocate should be informed of progress at all times.

Background

  1. In March 2018 Mrs G fell at home and fractured her pelvis and neck of femur (hip). Around six weeks later she fell at home again and was admitted to hospital on 18 April. On 20 April she had a fall in hospital on the Acute Medical Unit. Staff documented that Mrs G slipped while using the toilet, having been taken there by a healthcare assistant. A doctor assessed Mrs G after the fall. The doctor noted Mrs G was communicating coherently and was moving all her limbs freely and without pain. The doctor asked the ward staff to ensure Mrs G was not mobilising without supervision.
  2. Mrs G became critically unwell on 21 April because of a heart attack and septicaemia. The medical team treated and stabilised her.
  3. On 24 April staff noted Mrs G’s right elbow was tender. An x-ray showed she had fractured her right elbow. This was thought to have been caused by the fall in hospital four days earlier. She was put into an elbow cast. On 25 April Mrs G was transferred to an elderly care ward. The doctor there decided to arrange a CT scan of Mrs G’s pelvis as staff noted she had some bruising and pain around the hip, pelvis and groin.
  4. The Trust took specialist pelvic orthopaedic advice from a different Trust on the pelvic CT scan results. The specialist advice said the pelvic fractures showing on the CT scan were ‘mostly old’ and ‘not thought that the fractures were new’. The specialist advice the Trust received was that Mrs G did not need surgery on her hip. The bones appeared to be starting to heal and the Trust were to arrange a follow‑up appointment in the orthopaedic fracture clinic six‑weeks later.
  5. Staff told Mr T about his mother’s fall in hospital, on 26 April. Mr T complained to the Trust’s Patient Advice and Liaison Service (PALS) about the fall and the delay in telling him about it, the next day.
  6. During May 2018 hospital and social services staff spoke with Mrs G about her preferred discharge destination - back to her home with carer support, or into a care home placement. Mrs G said she wanted to go home and understood the potential risks associated with this. Trust staff and the social worker considered that Mrs G had the mental capacity to make this decision. Staff documented they were aware Mr T had concerns and felt his mother would be better going into a care home. Staff met with Mr T on 18 May to discuss discharge plans. They explained that Mrs G had capacity to decide to return to her own home and said the discharge date would be 21 May. They also explained that occupational therapy, physiotherapy and the medical team had reassessed Mrs G a number of times and they considered she was ready for discharge. Social services arranged for a care package at home consisting of four visits per day.
  7. The Ward Sister phoned Mr T on 21 May to let him know his mother was returning home that day. Mrs G’s discharge from hospital was delayed. The Trust said it asked the care agency to make the first call at 6pm instead, although the care agency disputes this.
  8. Hospital transport documented they arrived at Mrs G’s home at 17:26 and left at 18:01. The following day the Council recorded that the care agency told it a carer arrived at 6.10pm but that Mrs G was not at home so the carer visit did not take place. The care agency has subsequently told the Ombudsmen the Hospital cancelled the evening visit and the first call actually took place the following morning.
  9. The next morning, 22 May, carers found Mrs G collapsed on the floor when they made their morning visit. The ambulance service sent a welfare concern to the Council, as the crew found no food in the kitchen for Mrs G, the accommodation was ‘very unkempt’. The ambulance took Mrs G back to hospital as they did not consider they could leave her alone for welfare reasons.
  10. Staff met with Mrs G and her son after her readmission to hospital. The family said they were upset as the Trust had given them very little notice of Mrs G’s discharge the previous day. The family said they had not had time to make sure Mrs G’s flat was clean and fit for her to return to, or to get food in for her. The family also said the Trust’s decision to discharge Mrs G back to her own home surprised and disappointed them.
  11. On 23 and 24 May Mrs G’s consultant assessed her again and discussed her family’s concerns about her returning home. The records show Mrs G was adamant she wanted to go home and not into a care home. The medical team considered Mrs G still had capacity to understand the risks and make the decision. The Trust therefore planned for her discharge home again. She left hospital on 29 May 2019. The Council arranged carer visits four times a day, plus support from the Red Cross with shopping and cleaning.
  12. On 31 May Mr T contacted social services to raise concerns about his mother’s ability to cope at home. He arranged for a home visit by her GP, and the GP contacted the social services Rapid Response Team and arranged for Mrs G to return to hospital. Doctors in A&E saw Mrs G and agreed, with her consent, that she should go into a care home for rehabilitation. She went to the care home the same day.

The complaint

  1. Mr T initially complained to the Trust’s PALS Team on 27 April, about his mother’s fall in hospital and the failure to tell him about it. Mr T raised a number of concerns with his mother’s medical team during her time in hospital in April and May 2018. He also made formal complaints to the Trust.
  2. The Trust provided two written complaint responses to Mr T.
  3. The social care records show the Council asked its Brokerage Team to investigate the failed discharge and lack of carer visit. However, the Council said the investigation did not happen. It later raised this issue with its safeguarding team and asked this to be discussed at the Learning and Reflection Committee. A safeguarding strategy meeting took place on 12 August 2019 with the Council and the care agency. The safeguarding investigation case conference meeting took place on 23 September 2019 but its decision was ‘inconclusive’. The care agency did not attend the conference meeting and the findings largely focused on the Trust’s actions.

Analysis

Communication

  1. Mr T complained the Trust did not tell him (as his mother’s next of kin) that she had been admitted to hospital in April 2018, and he only found out from his mother’s home carers. He also complained the Trust did not tell him about Mrs G’s fall in hospital on 20 April until six days later. Mr T said the Trust did not give him enough notice of his mother’s discharge home on 21 May, and it did not make him aware of the date in advance. He also said the Trust failed to tell him Mrs G about Mrs G’s discharge from hospital to a rehabilitation facility on 31 May.
  2. The Trust acknowledged it had not told Mr T about his mother’s hospital admission in April 2018. It also accepted there was a delay in telling him about his mother’s fall on 20 April. The Trust apologised for these failings in communication and said it would raise the issues as learning points at monthly Clinical Governance Meetings, to try and prevent this from happening again.
  3. The Trust has accepted fault and the remedial action seems a reasonable and proportionate remedy. However, the Trust has confirmed it did not take minutes of the Clinical Governance meetings for the months following Mr T’s complaint. Therefore there is no evidence of this remedial action being taken. As Mr T has not received assurances the Trust raised these issues to reduce the risk of a recurrence, the injustice to Mr T remains unremedied .
  4. Mr T disputed the Trust’s response that it had told him about the planned discharge date of 21 May in advance and that he had not raised concerns about the date at the time. The Trust and Council records document that Mr T was told of the expected date of discharge at a family meeting on 18 May 2018. The record states: ‘both the patient and son demonstrated full understanding and voiced no concerns. [Mr T] had been concerned about discharge home earlier in the week….however he was much happier having seen his mother well and mobile on the ward’. The records also show that Mr T and his mother ‘agreed to the package of care to commence on Monday 21/05/18.’
  5. On the day of Mrs G’s discharge the notes show the hospital and the social worker contacted Mr T to confirm his mother was going home. Although Mr T does not recall being told this information, based on the available evidence, on balance I consider the Trust and the Council told Mr T of the date in advance. There is therefore no fault in this regard.
  6. The Trust failed to tell Mr T that his mother had transferred from hospital to a rehabilitation facility on 31 May. It said it would not always contact the next of kin in this situation unless there were any specific concerns. It also noted Mrs G had capacity to make decisions and she was happy with the plan.
  7. However, the records show that Mr T had been involved in discussions about his mother’s care and discharge planning from late April 2018 onwards. This included attending family meetings and both the hospital and social services had been contacting him direct. The notes show the Emergency Department had Mr T listed as the next of kin and had his contact details.
  8. During a meeting with Mr T on 3 May to discuss concerns about Mrs G’s care, the hospital consultant documented that Mrs G was elderly and vulnerable. The consultant noted that communication with family was crucial.
  9. The Trust’s discharge policy states: ‘it should be clearly identified who else the patient wishes to be informed and/or involved in the discussions and decisions regarding discharge…’ and ‘Please keep the patient, their family, carer or advocate informed of progress at all times.’
  10. The Trust’s actions do not appear in line with its own policy, particularly as Mr T had been so involved in his mother’s care planning. It is also notable that Mrs G was 93 years old with reduced mobility and was unlikely to have had the means to easily let her son know herself about her discharge. I therefore find it was fault by the Trust not to have informed Mr T about his mother’s discharge or tell him where she going to. This caused Mr T distress.

Fall in hospital

  1. Mr T said he believed his mother’s fall in hospital happened because staff were not adequately supervising her.
  2. The Trust said it reported and investigated the fall in accordance with its Policy for the Prevention and Management of Patient Falls (2018). The Trust’s complaint responses did not explain what measures were in place to manage Mrs G’s risk of falling after her admission to hospital.
  3. National guidance states that older people admitted to hospital because of a fall or report recurrent falls in the past year, should be offered an assessment of their risk of falling. Any necessary interventions should then be considered to address any identified risk factors.
  4. The Trust did a falls risk assessment on 19 April 2018, the day after Mrs G’s admission. However, it did not complete this correctly. It did not take Mrs G’s previous history of falls into account. This was fault.
  5. There is no evidence the Trust completed a moving and handling risk assessment. This was not in line with Manual Handling Regulations and is fault. As a result, there was no identified plan of care that considered what assistance Mrs G needed, such as transferring on and off the toilet. However, the physiotherapy assessment of Mrs G on 19 April states that she requires the assistance of one with toilet transfers.
  6. The falls incident report completed by the Trust on 21 April 2018 states that Mrs G suffered ‘no harm’. However, a scan four days later identified Mrs G had in fact fractured her elbow in the fall, and had potentially suffered an additional injury to her hip or pelvis. The incident report should have been updated to reflect the new information. It is fault that this did not happen.
  7. A further falls assessment is documented for 21 April, the day after Mrs G’s fall in hospital. This assessment did note Mrs G’s history of falling and that she needed the help of two people with mobilisation and transfers. The risk score was more reflective of her needs on admission.
  8. The records show the Trust did not complete a Falls Care Pathway until 29 April. This was 11 days after Mrs G was admitted to hospital and 9 days after she had a fall in hospital. A post falls pathway should have been put in place immediately after the fall on 20 April.
  9. It is evident Mrs G was at risk of falling during her hospital admission. In line with National guidance, the Trust should have completed a multifactorial risk assessment or implemented of a Falls Care Pathway to address modifiable risk factors at the earliest opportunity. It is fault that this was not done.
  10. In terms of the injustice to Mrs G, it is not possible to say what interventions the Trust should have implemented to minimise the risk of her falling. This is because the Trust failed to do a multifactorial assessment on admission and did not update the incident report when new information became available. Also, the Trust must carefully balance minimising the risk of falls with meeting a patient’s privacy and dignity needs. National guidance states all people should be able to use the toilet in private. The records do not indicate Mrs G could not use the toilet without assistance once staff had helped her to transfer. Additionally, there is no indication Mrs G would not have been able to call for help (by using the nurse call bell) to transfer off the toilet. The records show Mrs G did not ask for help and slipped on her own urine. I therefore consider it is unlikely Mrs G’s fall on 20 April was preventable. However, the faults with the assessments and care planning caused uncertainty about what may have happened had the Trust followed the correct procedures. This has caused Mr T distress.

Delays identifying fractures

  1. Mr T complained that his mother fractured her elbow and hip/pelvis in the fall but there were delays in identifying the fractures. He considered the Trust failed to carry out adequate assessments of his mother after her fall. This meant the Trust did not identify her elbow fracture until four days later, and her hip fracture even later than that. Mr T said the Trust staff told him contradictory information about what happened and he felt they were trying to cover things up.
  2. A doctor medically assessed Mrs G after her fall. The records show the assessment was appropriate. Mrs G did not complain of pain, she had full range of movement of all limbs and no sign of a head injury. No investigations were indicated and a the doctor recorded a reasonable plan for falls prevention. The Trust appropriately focused clinical care on Mrs G’s heart and general health issues.
  3. The first record of Mrs G complaining of pain was on 24 April. The physiotherapist noted she had bruising and tenderness on her right elbow and she complained of pain when mobilising. The medical team requested an X-ray which showed a fracture to her right elbow. Because of her other health problems, the medical team managed this conservatively with pain relief. This was clinically appropriate. The medical team also sought a specialist orthopaedic opinion and arranged for a CT scan the following day. This plan was appropriate for Mrs G’s clinical presentation.
  4. The records show the CT scan did not identify any new fractures. The doctors felt local pain from bruising following Mrs G’s fall at home was the cause of her pain. There was no indication for surgery or other interventions. Conservative management with pain relief and physiotherapy was the correct approach.
  5. I have therefore not found fault by the Trust in its actions regarding assessing and treating Mrs G’s injuries following her fall on 20 April.

Discharge home - 21 May 2018

  1. Mr T complained the Trust allowed Mrs G’s discharge home on 21 May despite him raising concerns that she was not fit for discharge. Mr T also said he did not consider the micro‑environment at home and the care package put in place by the Council were adequate for his mother’s needs. He said the family had not had time to make sure the flat was clean and fit for her to return to, or to arrange to get food in for her.
  2. The records show Mrs G had a full multi-disciplinary team assessment and discharge planning at the hospital. The medical team, occupational therapists and physiotherapists all reviewed Mrs G to assess her fitness for discharge from hospital. The multi‑disciplinary team had decided she was fit for discharge home with an appropriate care package in place and a micro-environment set up in her home.
  3. The records show Mrs G was clear she wanted to return home rather than go into a care home. The Trust assessed her as having mental capacity to understand and make decisions about her discharge arrangements. This included the risk of falling, which the Trust staff discussed with her. Ideally the discharge from hospital would have taken place earlier in the day, in line with the Trust’s policy, but this was delayed until the afternoon. However, records show the Trust told the carers about the delay and Mrs G was home before the time of the scheduled evening carer visit. The Trust noted Mr T’s concerns about the discharge and discussed this with him. The records indicate he reluctantly accepted the decision.
  4. The Mental Capacity Act 2005 and the related Code of Practice make it clear that individuals are presumed to have capacity unless there is proof to the contrary. People who make what appear to be unwise decisions should not be treated as not being able to make the decision just because others do not agree.
  5. Mrs G was medically fit for discharge and she had the capacity to decide her discharge destination. In terms of the Trust’s role, it was assured an appropriate care package was in place before Mrs G left the hospital. It also gave Mr T plenty of notice of the discharge date. I have therefore found no fault with the Trust’s decision to discharge Mrs G to her home.
  6. In relation to Mr T’s complaint about the micro-environment, the occupational therapy notes for 17 May state that Mrs G’s armchair had been moved into her bedroom. It is recorded that Mrs G agreed to only mobilise when carers were present. The Council’s social care records also note an armchair had been moved into Mrs G’s bedroom. Mrs G’s assessments in hospital noted she could mobilise with assistance of one.
  7. The evidence shows a micro-environment had been set-up with a bed and a chair in the room. The records also show Mrs G had agreed to mobilise only with assistance. This appears to meet Mrs G’s assessed needs, at least in the short term. This was not reason to delay Mrs G’s hospital discharge. I therefore find no fault in this respect.
  8. Mr T also complained the family had not had time to make sure the flat was clean and fit for Mrs G to return to, or to arrange to get food in for her. The Trust and Council records show they had told Mr T of the planned discharge date of 21 May at a meeting on 18 May. They recorded that Mr T and Mrs G understood this agreement and voiced no concerns. The Council offered to make a referral to the Red Cross to help Mrs G with food shopping, but she declined this as she said her friend would help out. Mr T was also contacted on the day of discharge with confirmation that it was going ahead. The records show that Mr T told the Council he would tell Mrs G’s friend. I consider the Trust and Council provided sufficient notice of the discharge date to give the family time to put arrangements in place for food in the flat and any cleaning necessary. I therefore find no fault in this regard.

Carer visit on 21 May 2018

  1. Mr T said after the Trust discharged his mother from hospital on 21 May, a carer did not see her until the following morning, when they found her collapsed on the floor.
  2. There is conflicting information about this issue. The Council’s record from 22 May 2018 notes the care agency told the Council a carer called to Mrs G’s home at 12pm but when no one was there they called the hospital. The hospital advised Mrs G’s discharge had been delayed but they should return at 6pm. The Council records say the care agency said the carer called again at 6:10pm, but no one was at home. There is no evidence the care agency reported this to the Council or the Trust.
  3. The Trust and the care agency records agree the hospital telephoned to cancel the lunchtime and afternoon visits. However, the care agency also noted the hospital would inform them when Mrs G was ready for discharge. The care agency said it had no further contact and therefore did not attend Mrs G’s home for the 6pm visit. The Trust said it did not cancel the evening call.
  4. Due to the contradictory records it is difficult to say exactly what happened or what was discussed between the three parties. There is agreement in the contemporaneous records that the Trust cancelled the early calls, but what happened with the 6pm visit is less clear.
  5. The care agency says it did not visit Mrs G on 21 May and there is no record of the carer contacting the Council on that day. However, the Council records noted the following day the carer said they had called just after 6pm, but there was no response.
  6. While it is unlikely the Ombudsmen can say exactly what happened given the conflicting accounts and the time since the events, it is clear there was a breakdown in communication between all the organisations and inaccuracies in at least some of the records. However, whether or not there was a carer visit or a lack of follow-up with the social care team, there is fault. This meant Mrs G had no carers calling until the following day. The information available suggests that Mrs G did not receive any assistance for her needs for around 15-hours.
  7. As a result of the fault, the social care team was not aware that Mrs G had not received her carer visit on the evening of her discharge. Therefore the Council did not carry out any follow-up work to establish Mrs G’s whereabouts or ensure her well-being. However, I do not consider it is possible to conclude the fall would have been preventable had the visit either taken place or the carer had escalated through the appropriate channels. That said, the lack of a carer visit on 21 May and the delay until the following morning is likely to have caused Mrs G significant distress. This in turn caused Mr T distress on learning what had happened to his mother over this period.
  8. The social care records show the Council asked for an investigation into these events by its Brokerage Team, but this did not happen. A safeguarding investigation later took place, but the outcome from this was recorded as ‘inconclusive’.
  9. The Council told the Ombudsmen it has asked for the care agency to be called in for a quality assurance meeting, with a focus on how the agency quality assures its ‘no response’ policy. The Council said it is also going to offer safeguarding support to the care agency, will arrange a quality monitoring visit to follow-up these actions, and will consider any trends and wider learning. While these actions appear reasonable, I have not seen an action plan showing when or how the Council intends to complete these actions.

Discharge home - 29 May 2018

  1. Mr T complained the trust discharged Mrs G home again on 29 May, after her readmission on 22 May. He said he felt this discharge was unsafe.
  2. Records show the Trust assessed Mrs G again after her readmission to hospital on 22 May and the doctors considered she was medically fit for discharge. Mrs G wanted to return home.
  3. The records show the Trust arranged a meeting on 25 May with Mr T, medical staff, the ward sister, the social worker and the occupational therapist. Mr T discussed his concerns about Mrs G’s ability to manage. The medical staff emphasised that Mrs G had capacity to make decisions about her discharge, and on that basis the team was under a duty to respect her wishes. The Council records note arrangements were in place in readiness for Mrs G’s second discharge from hospital. This included a care package of four visits a day, a micro-environment set up at home, the Red Cross to help with food shopping, and use of a pendant alarm. Mr T also confirmed he would arrange for food to be bought in advance.
  4. There are numerous entries in the medical notes referring to Mrs G’s capacity to make decisions about her discharge destination. The Trust documented Mrs G could retain and weigh up information about the risks of returning to her home.
  5. The records show the Trust assessed Mrs G’s capacity daily while she was on the ward, and she maintained that she wanted to go home despite understanding the risks. The Mental Capacity Act 2005 and the related Code of Practice make it clear that individuals are presumed to have capacity unless there is proof to the contrary. People who make what appear to be unwise decisions should not be treated as not being able to make the decision just because others do not agree.
  6. I have not identified any fault about the decision to discharge Mrs G back to her home on 29 May. She had capacity to decide to return home after being advised of the potential risks. Appropriate care arrangements were also in place.

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Agreed actions

  1. The Council and the Trust have agreed to the following actions:
      1. The Trust will take action to ensure the lessons learned about the failings identified with communication have been shared with staff. Evidence of this will be provided to the Ombudsmen and Mr T.
      2. The Trust will apologise to Mr T for the distress caused by not communicating with him about Mrs G’s hospital discharge to a rehabilitation placement.
      3. The Trust will take action to ensure its staff are aware of their roles to keep families and carers informed in accordance with the Trust’s own discharge policy.
      4. The Trust will ensure its policies reflect the need to update/renew incident reports if new and relevant information later comes to light and communicate this to relevant staff.
      5. The Trust will ensure its staff are aware of their responsibilities with completing falls risk assessments and moving and handling risk assessments in line with Trust policy and national guidance. This should include the timely completion of a Falls Care Pathway when indicated.
      6. The Trust will apologise to Mr T for the distress caused as a result of the faults identified with falls assessment and care planning.
      7. The Council will produce and share an action plan to evidence the actions taken as a result of the failings identified with the failed carer visit on 21 May. This will evidence what steps have been/will be taken to prevent this from happening again. Actions will address record keeping for any contacts with other agencies and the correct procedures to follow if there is no response to carer calls. This action plan will be shared with the Ombudsmen and Mr T.
      8. The Council will apologise to Mr T for the distress caused to him and his mother as a result of the faults identified in relation to the carer’s failure to visit Mrs G on 21 May.
  2. The Council and the Trust has agreed to complete action b), f) and h) within one month of the date of the Ombudsmen’s final decision statement. They will complete a), c), d), e) and g within 3 months of the date of the Ombudsmen’s final decision statement.

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Decision

  1. I did not find fault with the Trust’s decisions to discharge Mrs G from hospital on 21 or 29 May, or with its communication with Mr T about the date of discharge.
  2. However, I found fault by the Trust with its communication with the family about Mrs G’s hospital admission in April 2018 and following her A&E admission in May 2018. It has agreed actions to remedy the distress caused by the faults.
  3. I also found fault by the Trust with its falls risk management. I could not say Mrs G’s fall was preventable but the Trust has agreed action to address the faults and the distress caused to Mr T.
  4. I did not find fault by the Trust in relation to delays identifying elbow and pelvis fractures.
  5. I found fault by the Council regarding the failure of a carer visit to Mrs G after she was discharged home on 21 May. However, I could not conclude this was a factor in Mrs G falling. The Council has agreed actions to remedy this aspect of the complaint.
  6. In my view, the actions the Trust and Council have now agreed to take represent a reasonable and proportionate remedy to the injustice to Mrs G and Mr T arising from the faults.
  7. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman

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