Summary: We uphold Miss Y’s complaint about her father’s hospital discharge and care. We found fault with the way Mr X was discharged from hospital, the care he received in a care home and some aspects of his hospital inpatient care. As a result, Mr X did not receive the care he was entitled to. Miss Y has also experienced distress and uncertainty. The Council and the Trust have agreed to apologise to Miss Y, and the Council has agreed to make systemic improvements and pay a financial remedy.

The complaint

1. Miss Y complains about the care and treatment provided to her father, Mr X, by Bath and North East Somerset Council (the Council) and Royal United Hospitals Bath NHS Foundation Trust (the Trust).
2. She complains about the care provided to her father when he was placed in the Council run care home Charlton House Community Resource Centre (the Care Home). Specifically, she complains about
• the actions of an Occupational Therapist,
• her father’s catheter care,
• Urinary Tract Infection management; and
• poor record keeping
3. Miss Y is also unhappy with the handling of her father’s hospital discharges by the Council and the Trust. She complains about the decision to discharge Mr X to the Care Home in October 2022 and says she was not involved in the decision. She also says Mr X was unsafely discharged home in November 2022.
4. As a result, Miss Y says that Mr X did not receive an appropriate standard of care in his final months of life. She also says that she has been caused significant frustration and distress.
5. Miss Y would like any acknowledgement of fault, systemic improvements and financial redress.

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The Ombudsmen’s role and powers

6. 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).
7. 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.
8. The Ombudsmen may investigate, and question the merits of, action taken in the exercise of clinical judgement.
9. 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

10. I have considered the information Miss Y provided in support of her complaint. I have also received information from the Council and the Trust, including Mr X’s medical records, the Care Home’s daily records and the social worker’s case notes. I also considered independent clinical advice from a consultant physician and geriatrician. I have carefully considered all the written and oral evidence submitted, even if it is not all mentioned within this decision statement.
11. I shared this draft decision with Miss Y, the Council and the Trust and I have considered the comments I received.

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What I found

Key legislation and guidance

Quick Guide: Discharge to Assess

12. ‘Definition of ‘Discharge to Assess’ – ‘Where people who [no longer need hospital treatment], but may still require care services, are provided with short term funded support to be discharged to their own home (where appropriate) or another community setting. Assessment for longer-term care and support is then undertaken in the most appropriate setting and at the right time for the person.’
13. ‘Wherever possible, people should be supported to return to their home for assessment. Implementing a discharge model where going home is the default pathway, with alternative pathways for people who cannot go straight home, is more than good practice, it is the right thing to do.’

Hospital discharge and community support guidance July 2022

14. ‘Planning and implementation of discharge should respect an individual’s choices and provided them with the maximum choice and control possible from suitable and available options.
15. This process should be person-centred, strengths based, and driven by choice, dignity and respect.
16. NHS bodies and local authorities should adopt discharge processes that, in their judgment, best meet the choices and needs of the local population. This could include the discharge to assess model…’

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

17. These Regulations set out the fundamental standards below which care should never fall. The Care Quality Commission (CQC) provides guidance for service providers on how to meet these Regulations.
18. Regulation 17 relates to good governance. Specifically, Regulation 17(2)(c) states care providers must “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provider”.
19. The CQC guidance for this section explains that “records relating to the care and treatment of each person must be kept and fit for purpose.”
20. The guidance goes on to say that records should be “complete, legible, indelible, accurate and up to date, with no undue delays in adding and filing information, as far as is reasonable.” In addition, records must “include an accurate record of all decisions taken in relation to care and treatment and make reference to discussions with people who use the service, their carers and those acting lawfully on their behalf.”

What happened

21. Mr X was an elderly man with complex care needs including dementia and cancer. He lived in supported living accommodation with daily visits from care workers. Mr X had a long-term catheter in place and experienced frequent urinary tract infections (UTIs).
22. In September 2022, Mr X was admitted to the Royal United Hospital in Bath with leg and hip pain, constipation and a UTI.
23. In October 2022, Mr X was discharged to the Care Home, via a Discharge to Assess placement, with the aim to return home following a period of reablement. The Care Home is provided and run by the Council. In June 2022, the CQC had published a report which rated the Care Home as ‘Requires Improvement’.
24. In late November 2022, discussions took place for Mr X to move back to the supported living accommodation. Mr X and his family were keen for him to return home. However, shortly before he was due to move, Mr X had two falls in the Care Home.
25. Mr X was taken to Royal United Hospital for an x-ray and was admitted. Mr X did not have a fracture, however he was experiencing significant leg and hip pain from cancer which had spread to his bones. Mr X was prescribed opioid based pain medication to help manage his pain. Mr X was treated with three days of antibiotics for a UTI.
26. A few days later, Mr X was discharged home as previously planned, with an increased care package. Shortly before discharge, Mr X was reviewed by the acute oncology team. He was also reviewed by the physiotherapy team, who found he was moving around the ward well, using a walking frame. He was given a suppository to treat constipation.
27. When Mr X arrived home, he was found to be very sleepy and confused. The accommodation manager was concerned about Mr X and put extra nightly checks in place.
28. Mr X fell early the next morning and was re-admitted to hospital.
29. In December 2022, the CQC published a further report which regraded the Care Home to ‘Inadequate’. The Care Home was no longer able to accept new admissions, so Mr X could not return there. Miss Y also did not want Mr X to return to the Care Home.
30. In late December 2022, Mr X was discharged to a long-term nursing care placement at a different care home.
31. Mr X died in January 2023.

Analysis

First discharge

32. Miss Y complains that, in October 2022, Mr X was discharged to a reablement placement at the Care Home without properly involving her in his discharge process. Miss Y complains that there was no choice about where Mr X would go. She is also unhappy that Mr X was placed in a Care Home with known problems and a CQC rating of “Requires Improvement”.
33. The Council was responsible for finding a suitable discharge placement for Mr X. The Council told me that, since the COVID-19 pandemic, care home placements have been extremely hard to source and sometimes only one suitable bed is available. However, the Council’s Brokerage Team told me that choice is not offered for Discharge to Assess beds, as this is a short-term placement to assess a person outside of an acute setting. An alternative placement would only be sought if the initial care home declined to accept a person.
34. The Care Home offered a placement to Mr X, which the family accepted, and therefore no alternatives were sought.
35. Care homes rated Requires Improvement by the CQC are generally still able to accept new referrals. In response to my enquiries, the Council noted that many homes are rated Requires Improvement but said that does not mean they are unsafe or provide poor care.
36. In this case, I am aware the Care Home’s rating dropped further, despite the CQC’s involvement. I also understand why Ms Y was unhappy with the discharge location. However, there was no fault with Mr X being discharged to the Care Home at the time. Due to a shortage of placements, it is sometime necessary to discharge people to care homes with a Requires Improvement rating.
37. The Hospital Discharge and Community Support Guidance – July 2022 (the Guidance) states ‘Planning and implementation of discharge should respect an individual’s choices and provided them with the maximum choice and control possible from suitable and available options….On discharge from hospital, people who have new or additional needs should be offered choices of onward care and support to aid their recovery….If a person’s preferred placement or package is not available once they are clinically ready for discharge, they should be offered a suitable alternative while they await availability of their preferred choice’.
38. The Guidance is clear people should be offered choices when planning their discharge, including choosing their preferred placement. The decision to only offer one placement to Mr X, with no alternative choices, is contrary to the Guidance. This is fault.
39. The Council has explained there was a high demand for care home placements at the time. On the day Mr X was referred, there was only one nursing bed available and more than one person needing a nursing bed. Mr X was given priority as it was in his best interests to leave hospital.
40. While I appreciate the complex challenges faced by the Council due to the lack of placements, there is also evidence that the Brokerage Team did not seek or offer alternative placements, where one suitable placement had been found. This was not in line with the Guidance.
41. I acknowledge the Guidance says ‘While NHS organisations should seek to offer choice to patients where such choice exists, in practice, there may be limited situations where an NHS organisation may decide to reduce the choice of services offered to people on discharge. Such situations include times of extreme operational pressures, for example, for the duration of the UK COVID-19 Level 4 National Incident.’
42. However, it goes on to say ‘a record should be produced of the considerations of the relevant discharging body in deciding to offer that patient a reduced choice, setting out all of the material considerations for and against doing so, and the balancing exercise between the patient choice duty in the NHS Act 2006, and relevant competing duties and countervailing factors.’
43. I note that only one nursing bed was available at the time of referral and therefore it would have been difficult, in practice, to offer Mr X a choice at that time. However, placement availability changes frequently and more places became available the next week. The Council considers choice was available to Mr X because an alternative placement would have been sought if Mr X’s family had declined the Care Home. However, I am not satisfied the family were given sufficient information about alternative options to make an informed decision. For example, Miss Y also says she would not have accepted the placement if she had known the Care Home was rated ‘Requires Improvement’. Therefore, I do not consider this amounts to a clear genuine choice being given.
44. The failure to offer Mr X a choice of discharge locations was contrary to the relevant guidance.
45. The Council has told me it is currently working on improving practices around discharge planning and support.

Second discharge

46. Miss Y complains that, in November 2022, Mr X was unsafely discharged back to his previous independent living placement which could no longer meet his increased needs. He fell within 24 hours and was readmitted to hospital.
47. Miss Y complains Mr X was given a suppository before discharge then left to deal with chronic diarrhoea at home alone. She says he also had an untreated UTI and strong pain medication, which made him confused. Miss Y says the care agency was so concerned, they added emergency overnight night 2 hourly checks. Miss Y says this was an unsafe discharge.
48. I have considered whether Mr X was discharged home with an untreated UTI. Mr X had a long-term catheter in place and was prone to recurrent UTIs. From Mr X’s hospital records, it is not clear whether he had a UTI on admission in November 2022. There were some indications of a possible UTI, but no symptoms which were solely due to a UTI.
49. However, Mr X was started on a course of Nitrofurantoin, an antibiotic used to treat UTIs, as the Trust appeared to think this was required. The ‘National institute for Health and Care Excellence (NICE) guidance for UTI (catheter-associated): antimicrobial prescribing’ states that the appropriate treatment for men is to consider changing the catheter, to obtain a urine sample and an antibiotics course of lasting seven days.
50. There is no recorded consideration of whether Mr X’s catheter should be changed, and this was not requested. Further, Mr X’s antibiotics were stopped after only three days as “UTI treated”. This is not in line with the relevant guidance. Three days of antibiotics would not have been sufficient to treat any UTI present.
51. Overall, Mr X’s UTI management was not treated in line with the relevant guidance. This is fault. It is not clear whether Mr X had a UTI on admission. However, the Trust felt it was appropriate to treat him for a possible UTI and this treatment was insufficient. This has left Miss Y with uncertainty about whether Mr X had an untreated UTI when he was discharged and whether this may have caused confusion and contributed to his fall.
52. Miss Y complains that Mr X was given a suppository before discharge and had to deal with the resulting diarrhoea at home, alone. There is little in the hospital records about Mr X being constipated. However, it appears he was treated with senna (a medication used to treat constipation) during admission. When this did not resolve the constipation, a glycerol suppository (an alternative treatment) was used, in line with the NICE guidance for treating constipation. Constipation can have serious side effects if left untreated, therefore it would have been important to ensure it was addressed. I appreciate Miss Y’s concerns that Mr X would have struggled to manage the side effects at home. However, constipation can be treated in the community and would not have been a reason to delay discharge. I have not found fault with Mr X’s constipation treatment.
53. Ms Y complains that Mr X was given strong pain medication which made him confused and sleepy, contributing to his fall. Mr X’s pain medication at that time was not sufficient and he was admitted with bone pain arising from his cancer. Mr X’s pain medication was increased, in line with the NICE guidance for managing pain; palliative cancer care. Opioid pain medication can also cause constipation, another reason why Mr X required treatment for constipation. Specialist advice was also sought, including Mr X being assessed by the acute oncology team on the day of discharge.
54. Mr X received increased pain medication while he was admitted, including a pain medication patch being added 3 days before discharge. While opioid pain medication can cause drowsiness, Mr X was not recorded as being unusually confused or sleepy while admitted. Changes to pain medication would also not have been a reason to delay discharge.
55. I have found that Mr X’s confusion was not fully assessed in hospital. While it was noted that Mr X had dementia and some confusion on admission, he should also have been tested for delirium but this was not completed. There were many potential causes of delirium for Mr X, including his pain, change of environment, possible UTI, constipation and his underlying cancer. All of these factors, aside from the possible UTI, were appropriately treated while he was admitted. There was no undue concern about Mr X’s level of confusion while he was admitted. Delirium can fluctuate or deteriorate suddenly. Delirium does not always delay discharge and returning to a familiar environment can improve delirium. Miss Y says it is unlikely Mr X’s accommodation would still be a familiar environment after he had been away from it for several months. Mr X’s delirium should have been assessed in hospital. However, there is nothing to suggest that he was presenting as delirious during the admission and a consultant noted that he did not feel delirium was present.
56. Overall, Mr X’s discharge was handled in line with the Guidance. The discharge planning took place throughout Mr X’s admission, including involvement from Mr X’s family, the hospital discharge team and relevant specialists, including two consultant geriatricians. Mr X was assessed by the physiotherapy team and acute oncology team on the day of discharge, and all agreed he was fit for discharge. Mr X was assessed just 1.5 hours before his transport was booked and able to move well around the ward, using a frame. The day before discharge, Miss Y had confirmed that his level of movement was the same as previously.
57. Quick Guide: Discharge to Assess explains that people are ideally discharged home where possible and appropriate. When Mr X was assessed by multiple professionals, he presented as fit to return home. Mr X and his family were also keen for him to return home, as previously planned. The care package had been increased in anticipation of Mr X’s increased needs.
58. Based on the hospital records, it appears Mr X’s condition deteriorated unexpectedly and suddenly on his journey home. While this is unfortunate, any deterioration after discharge could not have been foreseen.
59. Given how Mr X presented when he returned home, and the fact he fell less than 24 hours later, I can understand why Miss Y reached her view that this was an unsafe discharge. Unfortunately, Mr X was a high risk of falls generally. There were many reasons which could have contributed to Mr X’s fall and he received appropriate treatment for most of these factors during his hospital admission. It is not clear whether Mr X actually had a UTI, and even if he did, I could not say this was the sole reason for his fall.
60. Overall, Mr X appeared fit for discharge and all professionals, Mr X and his family agreed with the discharge plan. Mr X was considered to have capacity to decide his discharge arrangements and wished to return home. I have not found any evidence of poor communication between professionals. Unfortunately, Mr X deteriorated on the way home, which could not have been anticipated. Overall, I have found Mr X’s second discharge was handled properly.
61. However, failure to fully treat Mr X’s possible UTI properly assess for any delirium has caused Miss Y worry and uncertainty about the discharge process and cause of Mr X’s fall.

Catheter care management

62. I have reviewed the Care Home’s catheter care records. Unfortunately, there are gaps in the records. The Adult Indwelling Catheter Care Daily record sheets have not been completed consistently. Over half the catheter care records for Mr X’s stay were missing. The failure to keep adequate records is not in line with Regulation 17(2)(c) of the Health and Social Care Act 2008. This is fault.
63. I also had to cross reference multiple types of documents for information about catheter care, including the handover diary, general report sheets and nurse report sheets. This made it difficult to see the full picture of Mr X’s catheter care. While these documents detailed some catheter care records, there is no record to confirm that Mr X’s catheter bag was changed between 21 and 30 October 2022. The frequency with which the leg bag was changed is also highly variable with no obvious reason for this.
64. There are two occasions where it appears Mr X went more than 7 days between bag changes. This is fault and increased his risk of developing a UTI.
65. Due to poor record keeping, I have not been able to confirm that Mr X received proper catheter care management while he was staying in the Care Home. This is fault. As a result, I am not satisfied Mr X received the care he was entitled to and his family have been caused worry and upset.

UTI Management

66. Miss Y complains that the Care Home did not manage Mr X’s recurrent UTIs properly, which contributed to his falls.
67. Mr X had a long-term catheter and experienced frequent UTIs. UTIs are a known risk of long-term catheters and can be difficult to avoid entirely.
68. I have reviewed the Care Home’s records and found that every time the Care Home or Mr X’s family suspected Mr X may have a UTI, his GP was contacted for advice and urine samples provided.
69. While I have been unable to confirm that Mr X’s catheter care was carried out correctly, I am satisfied that the Care Home consistently took appropriate action to seek medical advice when required.
70. Mr X had complex care needs that increased his risk of falls. I would not be able to take a view on the extent that UTIs specifically contributed to his falls.

Actions of the OT

71. Miss Y complains about the actions of the OT. Miss Y says Mr X was left in pain after sessions and exercises were ‘a bit much’ for someone with bone cancer.
72. Our role is not to ask whether an organisation could have done things better, or whether we agree or disagree with what it did. Instead, we look at whether there was fault in how it made its decisions. If we decide there was no fault in how it did so, we cannot ask whether it should have made a particular decision or say it should have reached a different outcome.
73. It was for the OT’s professional judgment to decide how to conduct therapy visits with Mr X. I have considered whether the OT took all available evidence, and any concerns, into account when deciding how to conduct Mr X’s therapy visits.
74. I have reviewed the OT’s visits to Mr X at the Care Home. Mr X had the capacity to refuse therapy. I can see that he chose to do so on some days, saying he was too fatigued or did not wish to participate. The OT listened to Mr X’s concerns and rescheduled these sessions to another day. The OT also moved sessions to the afternoon, in line with Mr X’s preference. The Council has confirmed that the OT had access to Mr X’s medical records and was also based at the Care Home and therefore familiar with Mr X’s needs.
75. Mr X and his family were keen for him to return to living independently. To do so, Mr X needed to improve his mobility. There was therefore a difficult balance to be struck between managing Mr X’s pain while also helping him to regain sufficient mobility to return home, as he wished. I have not found fault in the way the OT decided to conduct the therapy sessions.

Record keeping

76. The Council has already accepted fault with the Care Home’s record keeping. The Council has apologised to Miss Y and implemented systemic changes to improve its record keeping. This includes simplifying documents for staff, regular audits to ensure accuracy and moving towards an electronic records system. The CQC are also monitoring the Care Home’s record keeping as part of its inspections. I am satisfied these are appropriate actions.
77. However, the lack of records around Mr X’s catheter care has impacted on our investigation and left Miss Y with uncertainty about the quality of care her father received.

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Agreed actions

Council

78. Within one month of my final decision, the Council will
• apologise to Miss Y for failings in relation to Mr X’s catheter care
• apologise to Miss Y for failing to offer Mr X a choice of discharge location in October 2022
• will pay Miss Y a total of £300 in recognition of uncertainty and frustration
79. Within three months of my decision, the Council will review its policies to ensure people are offered choice as part of this discharge process, or any decision to restrict choice is properly considered and recorded. The Council will also ensure that all staff are aware of any changes arising from this.

Trust

80. Within one month of my final decision, the Trust will apologise to Miss Y for failings in Mr X’s inpatient care, specifically in relation to assessing his delirium and UTI care.

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Final decision

81. I have found that fault with the way Mr X’s discharge was handled in October 2022. I have also found fault with his catheter care management and record keeping by the Care Home. There were also some failings in Mr X’s care during his hospital admission in November 2022. As a result, Mr X did not always receive the care he was entitled to. Miss Y has also been caused distress and uncertainty. The organisations have agreed to take action to remedy the impact of these faults.
82. I have not found fault in relation to the decision to discharge Mr X home in November 2022.
83. I have now completed my investigation.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman