Decision : Closed after initial enquiries
Decision date : 23 Oct 2023
The Ombudsman's final decision:
Summary: We will not investigate Mrs X’s complaints about Blackpool Borough Council and Lancashire and South Cumbria NHS Foundation Trust. We do not consider an investigation by the Ombudsmen could add to previous investigations by those organisations.
- Mrs X complains on behalf of her mother, Mrs Y (now deceased). She complains about:
- The discharge from The Harbour (part of Lancashire and South Cumbria NHS Foundation Trust) to Hollins Lodge Care Home (the Care Home) in May 2022. Mrs X says poor communication between the Trust, Care Home and Blackpool Borough Council meant Mrs Y was admitted to the Care Home, which later agreed could not meet her needs.
- The Care Home let a stranger take her mother home.
- The Care Home inappropriately discussed end-of-life care with the family.
- Mrs X says events have caused her avoidable trauma, on top of the grief of losing her mother.
- Mrs X would like the organisations to apologise and carry out improvements to its services to ensure others do not suffer similar fault.
The Ombudsmen’s role and powers
- The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe it is unlikely they could add to any previous investigation by the bodies. (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)
How I considered this complaint
- I considered the information Mrs X and the organisations sent to me, including their responses to my enquiries.
- Mrs X had an opportunity to comment on my draft decision.
What I found
The discharge from the Trust
- After a detention under the Mental Health Act, the Trust discharged Mrs Y to the Care Home in May 2022. The Council arranged and funded that placement under its duty to provide Section 117 aftercare. So, the Council was responsible for the care provided to Mrs Y at the Care Home.
- Mrs Y remained at the Care Home until October 2022, when she was later admitted to a different hospital and sadly died.
- Following a safeguarding investigation in February 2023, the Council recognised the discharge planning from The Harbour was poor. Specifically, the Council did not share important information, including Mrs Y’s social care assessment and care plan, with the Care Home. The Care Home did not have a full picture of Mrs Y’s complex mental health needs. Also, due to the urgency of the discharge, the Care Home did not carry out any assessments of Mrs Y before the move. As a result, the Council made the following recommendations:
- It introduced a checklist for social workers to complete before they commission a placement.
- Ensure it checks if the Home completed pre-admission assessments for all existing residents.
- Ensure care homes are aware of the need to complete pre-admission assessments before all discharges from hospital.
- Ensure the Council, Trust and Care Home are aware of their responsibility to share information with each other before discharging someone from hospital to a care home. Also, remove any barriers to information sharing between them.
- The Trust also recognised the information it shared with the Care Home did not fully explain how to support Mrs Y’s complex needs. It agreed to provide staff with training, which focussed on care planning and working with other organisations.
- I agree the Council, Trust and Care Home each acted with fault. Each organisation did not ensure the Care Home could appropriately support Mrs Y’s needs. Finding this out after Mrs Y’s death must have caused Mrs X distress. However, I am not persuaded an investigation by the Ombudsmen could anything more. Each organisation has learned from the fault and put important service improvements in place.
Mrs Y leaving the Care Home with a stranger
- Mrs X says a staff member at the Care Home told her that someone had taken Mrs Y back home to remove her mobility scooter.
- In response to Mrs X’s complaint, the Care Home and Council said there is no evidence a stranger took Mrs Y home. However, the Care Home reiterated to staff they should be booking visitors in and out.
- I do doubt Mrs X’s version of events as she remembers them. However, Mrs X has not provided any evidence, from the time, for me to consider in response to the Care Home and Council’s investigations. Therefore, I am not persuaded an investigation by the Ombudsman can achieve anything more. While I have not found the Care Home acted with fault, it has taken action to ensure it books visitors in and out. That is good practice.
The Care Home’s discussion about end-of-life care
- Mrs X says the Care Home inappropriately discussed end of life care with the family before a GP reviewed Mrs Y.
- In response to Mrs X’s complaint, the Care Home said the person who allegedly had those discussions was on annual leave the days before the GP review. Also, the Council was not able to conclude what (if anything) was discussed with the family about end-of-life care.
- Again, I do doubt Mrs X’s version of events. However, I am unlikely to be able to say, even on the balance of probabilities, what was said between the Care Home and Mrs X. Therefore, I am not persuaded an investigation by the Ombudsman can achieve anything more.
- I do not consider an investigation by the Ombudsmen could add to the previous investigations by those organisations.
Investigator's decision on behalf of the Ombudsman