Summary: There is no evidence of fault in the way the Council managed Mrs X’s discharge from hospital.

The complaint

1. Mr A (as I shall call him) complains that the Council did not properly manage Mrs X’s discharge from hospital. He says her family wanted her to return home with support, but instead she was discharged to a nursing home.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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What I have and have not investigated

4. Parts of Mr A’s complaint relate to actions of the local NHS Trust and the out of hours GP service, which are not in our jurisdiction to investigate. We have also written to Mr A to explain that we will not pursue some aspects of his complaint against the Council as there is no evidence that he was caused injustice as a result.

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How I considered this complaint

5. I considered the information provided by the Council and by Mr A. We spoke to Mr A. Both the Council and Mr A had the opportunity to comment on this draft statement, and I considered their comments before I reached a final decision.
6. This statement does not include all the information I have seen about Mr A’s complaint, but I am satisfied it provides sufficient detail to explain my findings.

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What I found

Relevant law and guidance

7. The Mental Capacity Act 2005 introduced the “Lasting Power of Attorney (LPA)”. An LPA is a legal document, which allows a person (‘the donor’) to choose one or more persons to make decisions for them, when they become unable to do so themselves. The 'attorney' or ‘donee’ is the person chosen to make a decision on the donor’s behalf. Any decision has to be in the donor’s best interests.

What happened - background

8. Mrs X had dementia and multiple health problems. Her family, including Mr A (a former nurse), cared for her at home. The Council records indicate there were some tensions between the family members who provided the care.
9. Mrs X fell ill during December 2021 and paramedics advised attendance at A and E on Christmas Day. Mrs X was diagnosed with a urinary tract infection and discharged home with antibiotics. Her condition worsened and on 3 January she was readmitted to hospital.
10. After Mrs X was diagnosed with urine retention and admitted to a ward, Mr A says he noticed the IV glucose drip had increased significantly. As he was unable to attract any assistance, he reduced the flow then alerted medical staff to what he had done.
11. As a result of concerns raised about Mr A’s action, Mrs X’s family were no longer allowed to visit her unsupervised on the ward. Mrs X’s social worker noted in the case records, “ASC will need to be involved with any decision making re discharge and that myself and colleague would visit (Mrs X) on the ward once medically stable to discuss options.”

What happened – discharge from hospital

12. The case records show the social worker discussed with Mrs X’s niece, who jointly held power of attorney for Mrs X, some options for Mrs X’s care on discharge from hospital. These included a package of care commissioned by the Council or Direct Payments for the family to employ carers.
13. In January 2022 the social worker met with a senior social worker and a legal officer to discuss discharge arrangements for Mrs X, who was now deemed to be medically fit for discharge. The senior social worker was involved as Mr A and some other family members were refusing to engage with the social worker any more and asked for her to be replaced.
14. After some discussions about concerns raised by different family members, it was agreed that the least restrictive option was for Mrs X to return home with a package of care provided by care staff: only the care staff would have access to Mrs X’s medications which would be held in a locked box, due to the safeguarding concerns raised following Mr A’s intervention with Mrs X’s IV drip, and concerns raised by Mrs X’s granddaughter that the family was not communicating with each other regarding medications while Mrs X was cared for at home. If it was not possible to arrange a care package, then discharge to an interim care home placement would be made.
15. The Council records show considerable discussion over the next few days over what might be possible to enable Mrs X to return home. One family member offered to move in with Mrs X and provide the care she needed until a care package could be arranged, but there were concerns she would not be able to manage that as well as her four children. Another family member, the joint LPA holder, said she had discussed with the other LPA holder Mrs X’s deterioration. She told the social worker they thought Mrs X now needed 24-hour care and said Mr A had stayed overnight at Mrs X’s much more frequently in the last few weeks before her hospital admission.
16. In the light of that discussion, the social worker contacted some care homes for availability.
17. The senior social worker contacted Mrs X’s sister (and LPA holder) to discuss the possibility of a care home placement. Mrs X’s sister said she did not think Mrs X was ready for a permanent placement yet but would benefit from an interim placement.
18. Once a placement was found the senior social worker and the social worker contacted the LPA holders to inform them. Both were in agreement with the arrangement. The social worker agreed the responsibility for the case should move to the senior social worker after the interim placement was achieved, “to ensure that the family's refusal of engagement with (the social worker) does not become a barrier to achieving best outcomes for (Mrs X) when considering long term needs following the transfer to a temporary placement.”
19. There was a delay in discharge as Mrs X’s condition deteriorated again. Mrs X was discharged to the care home on 1 February. She died in April before the placement was made permanent.

The complaint

20. Mr A complained formally to the NHS Trust in February 2022. Part of his complaint was that the Council had said Mrs X would either be discharged home to be cared for by carers, with all medication locked away and no family input, or she would be discharged to a care home. He described the situation as “blackmail”.
21. The Trust responded to the complaint and included a response from the senior social worker about this aspect of the complaint. He explained that the possibility of discharge home with a care package had been explored with the family but there were delays in identifying an agency with availability, and it was not possible to expect the family to manage Mrs X’s care needs at that time. He said subsequently the joint LPA holders identified that in their opinion, Mrs X needed care in a 24-hour setting and so the option of a discharge home was no longer pursued.
22. Mr A complained to the Health Service Ombudsman who referred this aspect of the complaint to us. Mr A says he considers this aspect of the complaint less important than the matters which preceded and followed it as the family chose the care home themselves.
23. In respect of the discharge arrangements, the Council says “At the time the Council was unable to commission a care package and it was discussed and agreed with the family that a temporary placement should be sought as an interim measure. The long-term plan was that, once the carers were available, a return home would be pursued. Later records indicate that there was a deterioration in (Mrs X’s) physical and mental condition whilst in hospital and at that time the family thought that a care home placement was a better option.”

Analysis

24. There were significant concerns from some family members about Mrs X’s care in hospital. Family members had looked after Mrs X for some time at home and were understandably dismayed by the prospect that they would no longer be able to do so.
25. However, the evidence I have seen shows the Council acted appropriately in discussing Mrs X’s future care with the joint LPA holders. It acted on their views as well as its own assessment of Mrs X’s needs. There is no evidence of fault in the way the Council managed Mrs X’s discharge to a care home which was agreed by both LPA holders.

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Final decision

26. I have completed this investigation on the basis there is no evidence of fault on the part of the Council.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman