Summary: We do not consider The Hillingdon Hospitals NHS Foundation Trust missed the opportunity to refer Mr Y for physiotherapy when it discharged him to a step-down bed.

The complaint

1. Mr X complains that London Borough of Hillingdon (the Council), The Hillingdon Hospitals NHS Foundation Trust (the Hillingdon Trust) and Central and North West London NHS Foundation Trust (CNWL Trust) did not jointly arrange and/or provide physiotherapy when the Hillingdon Trust discharged his uncle, Mr Y, to Parkfield Nursing Home (Parkfield – not subject to this investigation).
2. Mr X says Mr Y now cannot walk and is bed bound due to their failing. He says the organisations should provide a financial remedy to address that injustice.
3. Mr X says Mr Y must now pay the Council for care and support, which could have been avoided if the organisations provided physiotherapy. The Council should pay the full cost of that care package. Also, Mr Y lost furniture to make way for a hospital bed. Mr X says the organisations should pay for the lost furniture.

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The Ombudsmen’s role and powers

4. 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)
5. 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).
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 considered the information Mr X and the organisations sent to me, including their responses to my enquiries. I also considered the relevant national guidance and legislation.
8. Mr X and the organisations had an opportunity to comment on two draft decisions. I have considered any comments before making a final decision.

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What I found

Key facts

9. In late April 2021, the Hillingdon Trust admitted Mr Y after he fell at home. During the admission, physiotherapists reviewed Mr Y. During the first assessment, Mr Y could not stand from a chair, even with the support of two, but could safely use a sit-to-stand aid. He moved to a rehabilitation ward after a week. A physiotherapist said a walking frame gave Mr Y greater support when standing. Mr Y’s mobility varied during the admission and would sometimes engage with physiotherapists but needed encouragement.
10. In mid-May, the Hillingdon Trust started planning Mr Y’s discharge under the Discharge to Assess (D2A) process. The Hillingdon Trust decided to move Mr Y to a step-down bed in a nursing home to bridge the gap between hospital and going home. Mr Y could not return home until someone could his home was a safe environment. The Hillingdon Trust said Mr Y would need a package of care to meet his support needs. Parkfield Nursing Home (Parkfield) said it could support his needs. Mr Y moved to Parkfield on 14 May.
11. On 25 May, a Social Worker assessed Mr Y’s needs and decided he could return home but needed equipment to support him there. The Social Worker referred Mr Y to CNWL Trust’s Rapid Response Team (RRT), who agreed to assess him. The RRT is a community emergency service whose aim to stop unnecessary hospital admissions. The RRT noted Mr Y was anxious and had lost confidence to stand. Parkfield told the RRT they were hoisting Mr Y as they did not have the equipment to fully support him. Mr Y needed the assistance of two carers and encouragement to sit on the edge of his bed, and to stand from sitting. Mr Y had capacity and wanted to go home. The RRT agreed he should return home with support.
12. The next day, the RRT visited Mr Y’s home. They said furniture needed to be removed to make space for equipment such as a hospital bed and a hoist. The next day, the RRT told the Social Worker to contact them once Mr Y’s room was clear. The RRT closed the referral.
13. On 1 June, a nurse at Parkfield made a physiotherapy referral to CNWL Trust’s Community Adult Rehabilitation Service (CARS). CARS is a community-based therapy service for adults who had been discharged from hospital following a fall. The same day, the Social Worker asked the RRT who should be providing physiotherapy to Mr Y. The RRT said Mr Y was on a waiting list for CARS. Mr X later told the Social Worker and RRT he refused to remove furniture from Mr Y’s home. The RRT explained Mr Y had deteriorated and his muscles were weaker as he was bed bound. Mr Y then agreed to remove the furniture.
14. On 4 June, the Social Worker chased the physiotherapy for Mr Y. The RRT recommended Mr Y’s GP make another referral to the RRT, which they did.
15. On 7 June, the RRT discussed Mr Y with a nurse at Parkfield. The nurse was unsure what Mr Y’s mobility needs were. The RRT noted Mr Y had not mobilised since the admission. He required the assistance of two carers to sit on the edge of the bed but could not stand. The RRT advised carers to hoist Mr Y as it was not safe for him to sit up and stand himself.
16. The next day, the RRT noted Mr Y showed improvement with encouragement from staff. The RRT agreed to review Mr Y for the next five days, and to provide a sit-to-stand aid to Parkfield. However, Mr Y refused to engage again so the RRT closed the referral.
17. On 14 June, the Social Worker referred Mr Y to the RRT again. The next day the RRT reviewed Mr Y. It said Mr Y needed the assistance of two to sit and the edge of the bed and to hold on to the sit-to-stand aid. He could stand with support and moved from the bed to the chair. Parkfield agreed to attempt those transfers with Mr Y.
18. The same day a CARS physiotherapist reviewed Mr Y. Mr Y did not engage. They said Mr Y would benefit from a gentle approach and encouragement to improve his mobility.
19. Mr Y and Mr X also met with CARS, the RRT, Parkfield and the Social Worker to discuss Mr Y’s care and support and the discharge plan. Mr X said Mr Y had not received enough physiotherapy at the Hillingdon Trust or in Parkfield. Professionals noted Mr Y had capacity to not engage. A care package was agreed to support the discharge home – four calls a day by two carers. The RRT ordered equipment and agreed for CARS to take over the physiotherapy.
20. The RRT and CARS separately reviewed Mr Y over the next week. Mr Y’s engagement varied. Both the RRT and CARS noted Mr Y had the potential to improve his mobility with regular practice. But he needed to engage more.
21. Mr Y moved from Parkfield back home on 25 June. When Mr Y returned home, CARS closed its referral.

Analysis

22. The Hillingdon Trust said it did not make a physiotherapy referral to CARS on 14 May 2021 because Mr Y did not have any on-going rehabilitation needs. It said a step-down bed could safely support Mr Y’s mobility needs, and he had not previously engaged with the therapy team.
23. On the D2A form, the Hillingdon Trust said before Mr Y went home from the step-down bed (Parkfield), he needed a “…review of safety in transfers from bed to chair and progression of mobility as possible, pt [Mr Y] has not been mobile on ward, able to STS [sit to stand] with heavy ao2 [assistance of two]-high falls risk”. Mr Y also needed equipment to support his mobility. The RTT was responsible for assessing Mr Y’s mobility needs at Parkfield before he went home.
24. I do not consider the Hillingdon Trust acted with fault when it discharged Mr Y on 14 May. The Occupational Therapist who completed the D2A form said a step‑down bed could appropriately support Mr Y’s mobility needs and explained why. The D2A form did not state Mr Y needed ongoing rehabilitation from CARS. Therefore, I agree it did not miss the opportunity to make a physiotherapy referral.
25. It became clear during Mr Y’s stay at Parkfield that he needed more support (and equipment) for his mobility than Parkfield could provide. Parkfield was responsible for ensuring it could safely support his needs in line with the D2A form when it decided to accept him from the Hillingdon Trust. I do not consider Parkfield's request for support to meet Mr Y’s mobility needs was due to any fault by the Hillingdon Trust.
26. Parkfield referred Mr Y to CARS on 1 June and CARS assessed Mr Y two weeks later. While Mr Y waited to be seen by CARS, the RRT supported him between 26‑28 May and 7–10 June at Parkfield. The RRT’s support was short-term and Mr Y’s engagement varied. By 7–10 June, Mr Y had stopped engaging with the RRT which impacted his progress. I consider the RRT were willing to support Mr Y and planned how to best manage his mobility needs when he returned home. The RRT’s clinical records show they robustly reviewed Mr Y, encouraged him to take part and provided appropriate advice to Parkfield around Mr Y’s mobility needs. Mr Y had capacity to refuse to engage, and the RRT could not force Mr Y to take part. I do not consider the RRT acted with fault when supporting Mr Y.
27. I also do not consider the Social Worker missed any opportunity to make a physiotherapy referral to CARS.

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Final decision

28. I do not consider the Council or either Trust missed the opportunity to refer Mr Y for physiotherapy when it discharged him to Parkfield.

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Investigator's decision on behalf of the Ombudsman