Summary: The complainant, Mrs C, says the Council and the Trust failed to provide her late father, Mr J, with sufficient occupational health equipment and physiotherapy to enable him to achieve his potential for rehabilitation. She also said the lack of care planning and therapy had an adverse impact on her mother’s caring role and left her with out-of-pocket expenses. We found the Trust was at fault in the way it decided to reprioritise a referral from a doctor, and this led to a delay in physiotherapy being provided. The Council took too long to provide equipment better suited to Mr J’s needs. The Council and the Trust have agreed to our recommendations and will apologise in writing to Mrs C’s mother, make an acknowledgement payment in recognition of the injustice caused and act to improve the response to referrals and record-keeping.

The Ombudsmen’s role and powers

3. 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, and Health Service Commissioners Act 1993, section 18ZA)
4. 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)).
5. 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.
6. 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

7. I have considered information provided by the complainant, the Council, and the Trust. I have also considered clinical advice and the law and guidance relevant to this complaint.
8. All parties have been given an opportunity to respond to a draft of this decision.

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What I found

Law and relevant guidance

9. Sections 9 and 10 of the Care Act 2014 require local authorities to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to all people regardless of their finances or whether the local authority thinks an individual has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
10. Where an individual provides or intends to provide care for another adult and it appears the carer may have any needs for support, local authorities must carry out a carer’s assessment. Carers’ assessments must seek to find out not only the carer’s needs for support, but also the sustainability of the caring role itself. This includes the practical and emotional support the carer provides to the adult.
11. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014)
12. The NHS Constitution establishes the principles and values of the NHS in England. It sets out rights to which patients, public and staff are entitled, and pledges which the NHS is committed to achieve, together with responsibilities, which the public, patients and staff owe to one another to ensure that the NHS operates fairly and effectively. All NHS bodies, private and voluntary sector providers supplying NHS services, and local authorities in the exercise of their public health functions are required by law to take account of this Constitution in their decisions and actions.
13. Intermediate care is a multidisciplinary service that helps people to be as independent as possible. It provides support and rehabilitation to people at risk of hospital admission or who have been in hospital. The Department of Health published Intermediate Care – Halfway Home in 2009. Halfway Home identified rehabilitation and reablement as part of the ‘Intermediate Care continuum’, removing any separation and promoting integration in service provision.
14. NICE guideline [NG74], published September 2017 – Intermediate Care Including Reablement. This guideline covers referral and assessment for intermediate care and how to deliver the service.
15. Guidance on Manual Handling in Physiotherapy 4th Edition 2014. This says physiotherapists owe a duty of care to their patients, colleagues and employers. This includes treatment involving manual handling, delegation of treatment and the provision of manual handling guidance, advice and education.
16. The Council’s and Trust’s intermediate care service is delivered by interdisciplinary health and social care teams providing reablement, rehabilitation interventions to clients within their homes. The service model is consistent across East Sussex but expected to be delivered by several teams aligned to General Practitioner consortia boundaries, to enable local community focus.
17. The Joint Community Rehabilitation team (JCR) provides short term support of up to six weeks to people in their own homes, usually following discharge from hospital and sometimes after experiencing ill health at home. The service has access to home care, physiotherapy and occupational therapy which aims to support people to increase their independence with daily living skills. In Mr J’s case the Council’s community occupational therapist worked alongside a physiotherapist from the JCR.
18. There are three priority levels used by JCR in response to referrals received:
• Urgent – JCR aim to respond within 48 hours to prevent unnecessary hospital admission, readmission or immediate risk of carer breakdown.
• Routine – JCR aim to assess a patient within two weeks following a recent deterioration or change in function (for example due to illness, surgery or fall), so that they can benefit from timely rehabilitation to optimise their recovery.
• Low priority – JCR aim to carry out an assessment within six weeks for a patient with long standing difficulties, or who has had a gradual recent decline and may benefit from rehabilitation.
19. The ‘end PJ paralysis’ campaign was launched by England’s chief nursing officer after a successful pilot study and it resulted in hundreds of hospitals across the UK taking steps to ensure patients got up and dressed and took part in activities instead of being stuck in bed. It led to reductions in falls, pressure ulcers and resulted in shorter lengths of stay, as well as improvements in patients’ experience of hospital care. The campaign aims to get patients out of bed and dressed during the day, and then into chairs, activity rooms or to dining rooms for meals. Increased activity can help recovery, reduce muscle wastage, maintain independence and lead to patients being discharged from services sooner.

Background

20. The late Mr J lived with his wife, Mrs J, and had complex physical health issues including pulmonary fibrosis, epilepsy, hearing problems, high risk deep vein thrombosis and osteoarthritis, which impacts on dexterity, range of movement and mobility. He was involved in road traffic accidents in the past, and had progressive and reduced immobility, secondary to spinal surgery. Mr J's mobility difficulties meant he needed the use of a Zimmer frame to mobilise. He had previously experienced falls and a mini stroke in mid-2017.
21. In August 2017 Mrs J contacted the Council’s social care team and said she had to call an ambulance for Mr J at the weekend and the ambulance crew had told her he needed to be assessed by an occupational therapist (OT). The records show a referral was passed to the Neighbourhood Support Team (NST) for care management input.
22. On 29 September 2017, Mr J had a fall at home and the ambulance service were called to help him to get up. Due to concerns about his mobility, personal care, and the impact on Mrs J the ambulance service made a referral to the Council's Health and Social Care Connect (HSCC) team.
23. The HSCC team received the safeguarding referral from the ambulance service on 29 September. The report from the ambulance service summarised Mr J falling, having progressive immobility and that he was almost immobile at the time. The HSSC sent a notification to the Occupational Therapy Team as Mr J was already waiting for an assessment. The case note notification was marked as high priority.
24. Later the same day a Council officer contacted Mrs J by telephone in response to contact from the ambulance service. Mrs J confirmed the general practitioner (GP) had visited and recommended Mr J remain on bed rest awaiting referral to the District Nurses. Mrs J said her husband was very weak and could not transfer in and out of his wheelchair. Mrs J also said he could not get on and off a commode. The officer suggested respite care and gave Mrs J the number for the Emergency Duty Team in case she could not manage Mr J’s care needs over the weekend. Mrs J said she would manage over the weekend until the OT assessment which was due on the Monday. The officer telephoned the Joint Community Rehabilitation Team (JCR) who stated they had not had a referral and that they had previously declined Mr J due to his long-term needs.
25. Also, on 29 September, Mr J’s GP made a referral to the HSCC team requesting assistance. The referral marked the primary presenting needs as falls and mobility. The GP’s reason for referral is recorded as ‘increasing leg weakness and recurrent fall, under investigation by neurology and known osteoarthritis and history of epilepsy’. The GP marked the referral as Priority 3: contact within 24 – 48 hours. The service requested by the GP was ‘JCR Rehabilitation and Falls Prevention’.
26. The records noted the referral did not have enough information and recorded ‘to call client to obtain information about which service is required’. The records show a record of the call from the HSSC to Mr J. Mr J said he could not hear the telephone and asked the HSSC caller to speak to Mrs J. Mrs J advised the HSSC that Mr J had experienced a mini stroke three weeks ago which had caused further deterioration in his mobility. Following this call the HSSC sent the referral to the Community Stroke and Rehabilitation Team (CSRT).
27. The CSRT received the referral a day later and noted ‘this patient is better for JCR rehab and not CSRT due to ongoing deterioration. Please refer as stated on the referral form to JCR rehabilitation’. The CSRT then emailed the referral to the JCR marked as urgent.
28. The JCR received the GP’s referral on 30 September. The Trust said when a referral is received by JCR it is initially triaged by a qualified member of staff (duty clinician) who will gather information to establish the appropriate response time. The duty clinician contacted Mrs J by telephone and noted that Mr J was due to have a visit from an Occupational Therapist (OT) the next day. In view of this the JCR planned to liaise with the OT following the visit.

Home visits made by the Council’s and Trust’s officers

29. The OT visited Mr and Mrs J on 2 October. The OT noted the equipment currently in place at the property and that Mrs J was finding it difficult to manage Mr J’s care needs. Mrs J said, ‘she does not feel able to provide physical assistance anymore’. The OT noted Mr J was continent using a bottle but was using pads for bowel movements or trying to stand while his wife held the pad below him. Mr J said he was holding his bowel movements because he could not use the toilet.
30. The OT observed Mr J completing a bed transfer with the help of Mrs J but when stood he was unsteady and only able to stand for a few seconds. The OT recorded that throughout the transfer Mr J experienced tremors, high levels of pain particularly from his right hip and when weight bearing. The OT recommended that Mr J needed hoisting equipment and a shower commode chair to meet his immediate need for safe transfers and toileting, access to seating and to reduce the risk of falls.
31. The OT said it was likely two people/carers would be needed for hoisting due to Mr J’s weight, level of pain and ability to participate. Mrs J expressed concern about financing a care package and how she would be able to manage when the carers were not present if Mr J wanted to use the toilet. The OT advised a financial assessment would need to be completed for care services and the timetable for potential carers considered once the equipment was in place. The OT recorded a plan to liaise with the JCR physiotherapist for a joint assessment, liaise with NST to request a care package/financial assessment and to complete a risk assessment for hoisting equipment and shower commode chair.
32. The OT contacted the JCR the day after her visit to Mr and Mrs J. The JCR had also attempted to contact the OT as agreed with Mrs J. The OT spoke to the duty clinician who agreed to progress the referral for a joint visit with a physiotherapist. The duty clinician advised that a physiotherapist would not be available until next week.
33. The NST contacted Mrs J by telephone on the same day and discussed the financial assessment process as Mrs J was concerned about care costs. The Council’s record of the call state Mrs J said Mr J’s need for support would be clearer once the equipment was in place and following his consultant’s appointment later in the month for muscle wastage. Mrs J wanted to explore further breaks for herself and ongoing care and respite for Mr J. The NST officer agreed to trigger the financial assessment and request a social care assessment for Mr J with a carer’s review for Mrs J.
34. The OT placed the order for the equipment two days after her visit and telephoned Mrs J to confirm the order. The OT also said she planned to complete a joint visit with the physiotherapist next week. Mrs J confirmed the equipment provider had been in touch about delivering the equipment. The OT told Mrs J not to use the equipment before the trial as incorrect use could cause injury.
35. The OT contacted the JCR about the date for the joint visit. The OT spoke to the physiotherapist who said she was on leave the following week and would not be able to visit until 24 October 2017. The date was booked for a joint visit. The OT also contacted the NST and asked the team to assess for carer support urgently.
36. The OT went to visit Mr and Mrs J a few days later with technicians from the equipment provider. The OT demonstrated how to fit the sling in a seated position and trialled hoisting Mr J. However, Mr J could not tolerate the transfer due to the pain he was experiencing. The OT helped Mrs J to complete a standing transfer with Mr J. The technicians moved the profiling bed into the living room where the hoist was fitted and a riser recliner chair in situ. Mrs J felt she could not hoist Mr J on her own and the OT contacted the NST about the request for a care package and left a message.
37. The OT planned to contact the GP’s surgery and request an urgent review for pain relief and bowel movements. Mr J could not be hoisted until suitable pain relief and carers were in place.
38. The OT spoke to a duty GP by telephone and explained it was not safe for Mr J to be transferred out of bed at that time. She said Mr J could not tolerate hoisting and so remained in bed until his pain could be managed. The OT asked the GP to complete a review for pain relief and bowel movements. The GP advised he would call Mrs J to collect a prescription to address Mr J’s pain and bowel issues.
39. A referral to the Council’s Crisis Response Team because Mrs J was unable to hoist Mr J was refused. The team said Mr J would not meet their criteria because their remit was to prevent hospital admissions. The team felt Mr J’s care could be managed at home. The District Nurses were also involved in Mr J’s care. The OT spoke to the District Nurse who confirmed Mr J’s skin was intact and no pressure wounds concerns were identified at the time.
40. The OT spoke to Mrs J who confirmed the GP had prescribed medication for bowel movements and pain relief. Mrs J said her husband was having the medication for bowel movements but was not taking the pain relief (pain patches) as it said not to use when someone had muscle weakness. The OT told Mrs J to discuss this with the GP. Mrs J said she would discuss pain relief options with the consultant at an appointment scheduled for the next day and would follow up with the GP. The OT spoke to the District Nurse who said they could not provide support with toileting or provide a bed pan. The District Nurse confirmed she had no pressure care concerns.
41. The NST spoke to Mrs J by telephone. Mrs J confirmed she could not mobilise
    Mr J to the commode but she was caring for him while he was in bed. Mrs J also said the GP had prescribed pain patches, but she was worried because the instructions said they should not be given to people with muscle wastage. The Council said Mrs J declined carers support preferring to wait for a visit the NST Officer scheduled for the next day.
42. The NST Officer visited Mr and Mrs J as arranged also present was their son. The officer confirmed she would make a referral to JCR to improve mobility. Mr J asked for a higher commode as the one in place was too low. The Officer noted that Mr J had muscle weakness and he was frightened of further falls. Mr J told the Officer he had a pressure sore on his back and the Officer agreed to advise the GP. Mr J consented to having a care package as he recognised his wife needed a break from her caring role. The Council’s records show the NST Officer tried to contact the GP surgery but was unable to get through.

OT and Physiotherapist joint visits

43. The OT and the physiotherapist completed a joint visit to Mr J as arranged.
    Mr and Mrs J’s son was also present for the visit. The Council’s notes state Mrs J told the officers that Mr J had been unwell, and the GP had been to see him several times over the weekend. In its complaint response letter, the Trust said
    Mr J had been suffering with diarrhoea and appeared drowsy. The Council’s and Trust’s records both support this view. The OT and the physiotherapist provided personal care as an immediate need but did not provide therapy as Mr J was in pain. A care package was not yet in place.
44. The officers discussed the option of respite care with Mr and Mrs J and their son. At the time, the NST was waiting for Mrs J to provide details about savings and how many care calls might be needed. The GP telephoned Mrs J during the visit and the physiotherapist spoke to the GP to provide an update. The physiotherapist determined that input was not appropriate at this time because
    Mr J was too unwell. The OT noted the gantry hoist was faulty and needed a repair. She arranged for the equipment technician to visit later the same day.
45. The next day the Council’s officers organised a care package to start in the evening of 25 October 2017. The OT advised Mr J was for care on bed and that he was only to be hoisted up over the bed to change the bedsheets, pads and personal care after toileting. The OT also advised Mr J should have pain relief before being moved or a sling fitted.
46. The OT spoke to the care agency a few days later about the care package. The care agency reported the carers had managed to support Mr J well during the three daily calls. The care agency said Mrs J had called to cancel the lunchtime call as Mr J’s diarrhoea had stopped. The care agency had advised Mrs J not to cancel the lunchtime call until the OT and the physiotherapist had completed their review. The OT also spoke to the GP surgery about Mr J’s medical health. A Locum GP reported that Mr J had health problems which impact his mobility. The OT arranged a further joint visit with the physiotherapist.
47. The OT and the physiotherapist went to visit Mr and Mrs J a second time on
    7 November 2017 to complete a joint review to see if he had stabilised enough for rehabilitation and transfer. The OT and the physiotherapist hoisted Mr J onto the commode and the records indicate he tolerated this well but was anxious when returning to bed. The physiotherapist gave him some exercises to do when he was sat on the commode three times daily (when carers visited). This involved
    Mr J sitting on a commode during support calls and low-level exercises such as toe tapping be performed.
48. Mrs J said she not giving Mr J regular pain relief. The physiotherapist spoke to the GP during the visit and the GP agreed to prescribe morphine for use as required together with paracetamol. The officers told Mrs J and the carers that Mr J must have pain relief before he is transferred. The records state the OT provided the carers with advice about hoisting (listed in the care records). The OT also sent an email to the Care Manager at the care agency with a written record of the advice.
49. The OT and physiotherapist completed a third joint visit a few days later. Mrs J reported that Mr J had not been hoisted onto the commode since the last visit. The records state Mr J had declined to be hoisted because he was feeling unwell. Mrs J said she did not have confidence in all the carers to hoist Mr J. Mrs J said she was unhappy her husband had been in bed this long. She also reported she had not been giving him regular pain relief. The OT and physiotherapist told Mrs J that Mr J needed rehabilitation in stages and the first part was having him sit out of bed on the commode to help build his stomach muscles. The officers said if
    Mr J was not given regular pain relief or hoisted out of bed onto the commode this would not be achievable.
50. The OT and the physiotherapist helped Mr J out of bed using the hoist so he could use the commode. The OT noted a noise coming from the hoist and advised it could not be used until checked by the equipment technician. The OT and physiotherapist remained concerned that Mr J was not making progress because the exercises and hoisting had not been carried out. The OT noted to complete moving and handling plan and request the technicians check the hoist. The physiotherapist noted that she could not progress rehabilitation at this time.
51. The next day Mrs J spoke to the OT and she said the equipment technician had visited to check the hoist and had reported it as fine. The OT confirmed the equipment provider had also confirmed this to her.

OT and Physiotherapist involvement end

52. A social worker, the OT and the physiotherapist went to visit Mr and Mrs J on
    22 November. Mr J said he did not want to be hoisted because it was painful.
    Mrs J said she did not see the point of giving her husband morphine so he could be hoisted as she did not think this was right. The social worker recorded advising Mrs J that if Mr J’s care needs could not be managed at home, he may need nursing care to reduce the risk of pressure sores and deterioration in his health. The social worker visited the GP surgery to request a review. The social worker also contacted the District Nurses about pressure care.
53. The OT and the physiotherapist completed another visit on 28 November. Mrs J said her family were unhappy with Mr J’s lack of progress. Mrs J sad she was not expecting a visit from the officers. She said she had also spoken to a private healthcare provider and had requested a private physiotherapy assessment.
    Mrs J said she was unhappy about having to chase up for equipment such as the shower commode chair. The carers from the care agency were present at the visit and one said they did not want to tilt the glide about commode chair to make positioning easier when Mr J was being hoisted. Mrs J said she did not want any further input from the OT and physiotherapist and asked them to leave. Mrs C said this was because her mother was unhappy with the officers because Mr J had been left in bed for too long and unable to access a toilet.
54. Later in December a professionals meeting was held because of concerns around providing therapy to Mr J and Mrs J’s decision not to allow the OT and physiotherapist to attend further visits. By this time Mrs J had commissioned a private physiotherapist and was using a privately commissioned mobile hoist. A social worker carried out a mental capacity assessment which determined Mr J could decide about his care arrangements. The OT and physiotherapist then discharged Mr J from their service.
55. The Council continued to deal with issues around Mr J’s care and support arrangements with care agencies. Mrs C later complained to the Council and the Trust on behalf of her parents, Mr and Mrs J. She then complained to the Ombudsmen.

Findings

The Council’s response to the safeguarding referral from the ambulance service

56. When the Council received the safeguarding referral from the ambulance service it acted to contact Mrs J on the same day. The officer ensured Mrs J was provided with the telephone of the Emergency Duty Team and established an OT was due to visit with 48 hours. Mrs J said she could manage until the OT appointment.
57. The evidence available now, suggests the Council quickly acted to establish the risk to Mr J. It then took appropriate action to ensure suitable follow up to the concerns raised by the ambulance service to minimise the risks to Mr J. I do not find the Council at fault.

The Trust’s decision to downgrade the priority level of the GP’s referral

58. It is likely the GP knew Mr J and had a good understanding of his presenting needs at the time the referral was made. The GP marked the referral as priority 3 and wanted a review with 24 – 48 hours. The JCR downgraded the referral and did not see Mr J until 24 days later. The Trust has not provided any clinical documentation to support the clinical judgement to downgrade the GP referral.
59. The service specification draft provided by the Trust does not provide any specific guidance about prioritisation of referrals at the point of acceptance. For example, when it might be appropriate to downgrade an urgent GP referral. The CSRT also emailed the JCR with a referral marked as urgent and the ambulance service notification was recognised as high priority. Although a staff member contacted Mrs J to discuss the referral it would generally be considered more acceptable practice to contact the referrer rather than the patient.
60. NICE guideline NG74, recommendation 1.5.3, states that for bed-based intermediate care, there is moderate-quality evidence to suggest that if the referral is made from acute care then the person's condition will begin to deteriorate if intermediate care does not start within 2 days. There is no clear evidence about the most effective timescale for people whose referral is being made in different circumstances, for example if they are at home and being referred for home-based intermediate care or reablement to prevent hospital admission or improve independence.
61. Based on the evidence available now it is likely the Trust’s decision to downgrade the referral and the subsequent delay in response time was not consistent with good clinical care and treatment. Therefore, I find the Trust at fault. The delay in the delivery of care is likely to have negatively impacted on Mr J’s progress with rehabilitation. Mrs J is likely to have experienced increased carer’s strain and distress.

The Council’s provision of suitable occupational therapy equipment

62. When the OT first visited Mr J she assessed the risk to Mr J transferring out of bed with a Zimmer frame but noted that he was weak and unsteady. In summary the OT did not think this way of transferring was safe. The OT identified he would need a commode and a hoist so he could be hoisted from the bed to a chair.
63. The OT would have used her professional judgement to decide what type of hoist and was best suited to Mr J’s needs based on his height and weight. The records suggest Mrs J did not believe the commode in place initially was suitable. She also expressed dissatisfaction with the hoist provided and the slings used.
64. On the evidence available now there is no evidence to suggest the hoist recommended by the Council’s OT was not fit for purpose. It is more likely that
    Mr and Mrs J preferred to have a different hoist they considered more suitable. In this event Mr and Mrs J hired a mobile hoist privately. Therefore, I find no fault in the way the Council decided to provide the hoist it chose.
65. The OT ordered a shower commode which she considered the best option for
    Mr J. The equipment provider told the OT this commode was out of stock. The OT asked the equipment provider to send a glide-about-commode instead. Although this was not the most suitable commode for Mr J the OT assessed it as being safe to use in the short term. This commode required carers to tilt it back when hoisting. However, the records available suggest that carers were reluctant to tilt the commode back and expressed reluctance to do so. This is likely to have impacted on the ability to hoist Mr J successfully.
66. The Council’s complaint investigation established the shower commode was out of stock for about eight weeks. This was likely too long and the delay in provision is likely to have impacted negatively on Mr J’s progress with rehabilitation.
67. The hoist needed two people to operate the equipment safely. There was a delay in the Council providing carers who could assist Mrs J with hoisting. This meant the equipment was in place but could not be used for a period.
68. The Council’s delay in providing two carers who could have assisted Mr J to be moved out of bed to the commode and then complete exercises is likely to have impacted on his progress with rehabilitation. This would have likely meant Mrs J experienced increased carer’s strain and distress.

The provision of a bed extension and infills

69. When the Trust responded to Mrs C’s complaint it found that a bed extension and infills would have been beneficial at the time. However, these were not provided at the time the JCR was involved in the care arrangements. This is likely to have impacted on how well Mr J could be positioned in the bed without this equipment and is likely to have been uncomfortable for him. In the complaint response the Trust apologised that a bed extension was not installed at an earlier date and said it had asked its officer to learn from this by reflecting on the benefits of a bed extension and infills for patients in future.

The Council’s consideration of the pain Mr J experienced when hoisting

70. The evidence available summarises the discussions the OT had with Mr and
    Mrs J about pain management. It is likely that Mr J was experiencing pain other than when just being hoisted. Mrs J confirmed she was not giving him pain relief consistently likely because of her concerns around how medication affected muscle wastage.
71. The OT liaised with the GP and when necessary advised Mrs J to speak to the GP about the concerns around medication. On the evidence available now, I find the Council appropriately considered the pain Mr J experienced when being hoisted. It contacted other agencies such as the GP for pain relief and the District Nurses who were responsible for pressure care management.
72. The complainant says Mr J was able to tolerate being hoisted when using the private commissioned hoist. I cannot say why this may have been as I have not seen reports from the private equipment provider or its comments on the suitability of the equipment the Council provided. In any case I do not find fault in the way the Council considered Mr J’s pain when being hoisted.

The Council’s and Trust’s communication with Mr and Mrs J including provision of suitable care plans, assessments and information

73. There is evidence of actions taken recorded in the care/clinical records for the Council and the Trust. However, I have seen less evidence to show what written information the Council and the Trust provided to Mr and Mrs J.
74. For example, the complainant says her parents were not provided with a written plan for occupational therapy and physiotherapy. The records show plans agreed between the OT and the physiotherapist, but I have not seen evidence to show these were written up into a plan and provided to the patient and his carer.
75. The Council and the Trust suggested Mr J’s health presentation at the time prevented them from completing written assessments and plans. It is likely that Mr J’s health presentation at the time would have prevented the officers from completing an assessment but this should not have prevented them from starting their respective written assessments which they could have eventually shared with Mr and Mrs J. The records provided do refer to a joint assessment being completed but there is no evidence to show a joint written assessment was completed.
76. The physiotherapists notes provided by the Trust are handwritten and hard to read. The physiotherapist has not printed his or her name clearly throughout the notes and there are errors in the date recorded. The Chartered Institute of Physiotherapists in its Records Keeping Guidance – November 2016 says “A good record will enable an independent reader to understand what conversations took place with a patient, what information was exchanged, the extent of any examination performed, what treatment was provided and what clinical reasoning decisions were made.”
77. Based on the evidence available which includes advice from the Ombudsmen’s clinical advisor it is likely the record keeping by the physiotherapist fell below expected professional body (Chartered Society of Physiotherapy) standards (2017). The poor record keeping is unlikely to have caused Mr and Mrs J any substantial injustice.
78. The OT created a Moving and Handling Plan on 14 November 2017 following joint visits with the physiotherapist. This shows the OT and the physiotherapist were working together to achieve rehabilitation goals. The plan listed the rehabilitation goals such as to improve Mr J's sitting tolerance so he could sit out of bed and access the commode and riser recliner chair. The plan also said the OT and the physiotherapist would be able to review Mr J’s transfers and make further recommendations once he had achieved the goals. It said the physiotherapy exercises were kept at home and the carers were able to assist and prompt Mr J to engage with his exercise programme.
79. The OT completed the plan, she sent instructions to the care agency commissioned by the Council. The OT did not share the moving and handling plan with Mr and Mrs J at the time and only appears to have done so after the care agency had started. This is likely to have contributed to Mrs J to feeling as if nothing was being done and that there was a lack of active ongoing therapy. It also meant Mr and Mrs J were not able to challenge or ask any questions about the written plan. This may have helped to alleviate their anxiety and provide more confidence in what both therapists were trying to achieve.
80. When it investigated Mrs C’s complaint the Council identified the NST’s officer’s communication should have been better. There is little evidence the officer provided written information about the assessment process, support plans, personal budgets, and choice of care agencies to Mr and Mrs B. The Council also said the officer should have completed a healthcare funding checklist. The failure in communication and provision of written information is likely to have caused Mr and Mrs J avoidable frustration and confusion at a time when they were already finding things difficult.

Mr and Mrs J decision to end their involvement with the Council’s OT and the Trust’s physiotherapist

81. The OT and the physiotherapist could not progress the rehabilitation goals they had agreed for Mr J. The evidence available suggests Mr J was not always well enough to actively engage in rehabilitation. The service was always going to be time-limited for a maximum of six weeks based on the service specification. Had rehabilitation progressed it is unlikely the OT’s and physiotherapist direct involvement would have continued far beyond six weeks.
82. The Trust said it recognised the need for early activity to reduce the negative impact of immobility in line with the ‘end PJ Paralysis’ campaign. The plan agreed between the OT and the physiotherapist was to get Mr J out of bed and sitting in a chair so that he could complete the relevant exercises prescribed. Mr J did not engage with the plan mainly because he experienced pain and there appeared to be a lack of confidence with the equipment provided. The evidence available shows the plan agreed between the OT and physiotherapist was consistent with good clinical care and treatment.
83. Mrs J eventually told the OT and the physiotherapist she no longer wanted their involvement. The Council established that Mr J had the mental capacity to make this decision. There is no doubt that Mrs J wanted to see her husband’s immobility improve and it is likely that Mr J wanted to get out of bed.
84. This led to Mr and Mrs J’s decision to enlist the services of a private physiotherapist and hire a mobile hoist. Mrs C says this was because of fault by the Council and the Trust and feels Mrs J should be reimbursed. Based on the evidence available, I do not find fault in the Council’s decision to provide the hoist it did or fault in the rehabilitation plan agreed by the OT and the physiotherapist. Therefore, it is not appropriate for the Ombudsmen to recommend the Council and the Trust repay Mrs J for private care costs.

Conclusion

85. The Council acted promptly to deal with the safeguarding alert from the ambulance service to minimise any risks to Mr J. The Council and the Trust already had a joined-up community rehabilitation service in place to respond to
    Mr J’s needs. There was fault in the way the Trust decided to downgrade the referral from the GP, and this is likely to have impacted adversely on Mr J’s rehabilitation goal and caused Mrs J to experience increased carer’s strain and distress.
86. The Council provided a hoist and commode it considered suitable for Mr J’s needs. The Ombudsmen do not find fault with the Council’s decision. The Council considered the pain Mr J experienced when being hoisted and contacted other professionals such as his GP who could provide pain relief. However, it was likely Mr J did not take pain relief consistently because of concerns about the medication. The Council delayed providing the preferred commode for about eight weeks and this is likely to have had an adverse impact on Mr J’s rehabilitation goals and caused Mrs J to experience increased carer’s strain and distress. The Trust also failed to provide a bed extension.
87. The Council and the Trust did not create a written assessment which could have been shared with Mr and Mrs J when their involvement started. However, there was a plan in place which was recorded in the case records. Poor record keeping by the Trust is unlikely to have contributed to any adverse impact on Mr J’s rehabilitation goals. However, the lack of written information and advice provided to Mr and Mrs J by the Council and the Trust is likely to have caused them confusion and frustration.

Improvements made by the Council and the Trust since considering Mrs C’s complaint

88. The Council confirmed it has made the following improvements since responding to Mrs C’s complaint:
• its equipment provider has created a new priority system for equipment provision which is monitored through the Council’s contract management.
• its managers have ensured all staff are aware of their responsibility to share written information such as short plans.
• the NST officer received direct feedback about the importance of communicating clearly and effectively.
89. The Trust confirmed it had worked with the Council to make the following improvements:
• when referrals are made by partner organisation, JCR will proceed with the usual protocol of patient contact, such as letter to the patient with contact details and advice on how to raise concerns.
• written exercise to be personalised appropriately across JCR.
• staffing numbers and activities have been modified to support improved responsiveness across the JCR localities.
• opportunities for other teams to share concerns about the lack of anticipated progress has been discussed with the Council.

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Agreed recommendations

90. Within four weeks of the final decision the Council and the Trust will:
• write jointly to Mrs J to apologise for the impact the delay in acting on the GP referral and delay in being able to use the hoisting equipment and preferred commode had on her late husband’s progress with rehabilitation.
• each pay Mrs J £500 (and on behalf of Mr J’s estate) in recognition of the adverse impact on Mr J’s wellbeing and the subsequent adverse impact on
  Mrs J’s caring role as well as the distress experienced.
• reminds their officers of acceptable good practice when referrals are received such as contacting the referrer for more information if this is considered necessary.
91. The Trust will remind its physiotherapists of the importance of good record keeping which should be in line with expected standards of performance, conduct and ethics and professional body standards.
92. The Trust will ensure it has a written procedure in place which is consistent with good clinical care and treatment to show how and when a referral to the JCR may be reprioritised from urgent to non-urgent or vice versa.

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Final decision

93. Faults by the Council and the Trust caused injustice to Mr and Mrs J. The Council and the Trust have agreed to our recommendations, so I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman