Summary: Mrs X complained on behalf of her father, Mr Y about the way Lincolnshire County Council and United Lincolnshire Hospitals NHS Trust discharged him from hospital to a care home, The Old Rectory. The Hospital Trust acted with fault when it discharged Mr Y and should apologise to Mrs X for the uncertainty it caused her. It should also take action to avoid similar fault. Mrs X also complained about Lincolnshire Community Health Service NHS Trust’s support for Mr Y’s pressure sores. We found the Community Trust should have started care planning sooner than it did. While that did not cause any injustice, it should take action to avoid similar fault in future.

The complaint

1. Mrs X complains for her father, Mr Y, about Lincolnshire County Council (the Council), United Lincolnshire Hospitals NHS Trust (the Hospital Trust), The Old Rectory Care Home (arranged and funded by the Council) and Lincolnshire Community Health Service (the Community Trust). She complains about:
1. The discharge from the Hospital Trust to The Old Rectory. She says there was a lack of communication between the Hospital Trust and Council, which meant it discharged Mr Y before it completed the appropriate assessments.
2. The decision to move Mr Y to The Old Rectory. It could not meet his needs, and he should have moved to a nursing home instead.
3. The Old Rectory and the Community Trust’s care and support for Mr Y’s pressure sores.
4. The Old Rectory inappropriately offered Mr Y food he could not swallow at the end of his life.
5. The Old Rectory did not administer all of Mr Y’s medications.
2. Mrs X says the failings above meant she had to witness Mr Y suffer at the end of his life, which was distressing and caused her anxiety. He lacked dignity in those final days.
3. Mrs X would like the organisations involved to make changes to ensure other families do not have a similar experience.

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The Ombudsmen’s role and powers

4. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
5. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we 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 it has, we 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.
7. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:
• the fault has not caused injustice to the person who complained
• it is unlikely we could add to any previous investigation by the bodies; or
• it is unlikely we would find fault

(Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

8. When investigating complaints, if there is a conflict of evidence, we may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
9. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our 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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What I have and have not investigated

10. I have investigated parts a) to c) of Mrs X’s complaint.
11. I have not investigated part d). I will explain why.
12. Mrs X says The Old Rectory offered Mr Y food he could not swallow at the end of his life. In response, The Old Rectory said it offered Mr Y alternative lunch options (which he could swallow) but accepted it did not document that. Firstly, I am not persuaded Mr Y suffered any injustice from being offered food he could not swallow. There is no evidence that caused him to choke. Also, The Old Rectory has recognised it should have recorded when it offered alternative foods to Mr Y and shown evidence it has learn from that.
13. I have not investigated part e). I will explain why.
14. When a GP visited Mr Y on 25 June 2022, they stopped prescribing most of Mr Y’s medication and focused on his pain relief. That was because the GP considered he was nearing the end of his life and should be comfortable. I am unlikely to find fault with The Old Rectory for not administering all of Mr Y’s medications. It was simply acting on the GP’s advice.

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How I considered this complaint

15. I considered evidence provided by Mrs X and the organisations as well as relevant law, policy and guidance. I also considered independent clinical advice from a registered general nurse.
16. Mrs X and the organisations had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Relevant law and guidance

The hospital discharge

17. Department of Health and Social Care issued statutory guidance: Hospital discharge and community support guidance (the National Discharge Guidance) in April 2022. This provides guidance to NHS bodies and local authorities on discharging adults from hospital. It said local areas should adopt discharge processes that best meet the needs of the local population.
18. In Lincolnshire, a Discharge to Assess model was in operation when Mr Y left hospital. It said Mr Y went home on Pathway 1 – for people able to return home with new or additional support.
19. The National Discharge Guidance said: “the vast majority of people are expected to go home (to their usual place of residence) following discharge. The discharge to assess model is built on evidence that the most effective way to support people is to ensure they are discharged safely when they are clinically ready, with timely and appropriate recovery support if needed. An assessment of longer-term or end of life care needs should take place once they have reached a point of recovery, where it is possible to make an accurate assessment of their longer-term needs… Everyone should have the opportunity to recover and rehabilitate at home (wherever possible) before their long-term health and care needs and options are assessed and agreed.”
20. The National Discharge Guidance says: “To implement best practice, NHS bodies and local authorities should work together to transfer people seamlessly and safely from hospital to their own home or a new care setting with joined-up care, based on clear, evidence-based and accurate assessments that fully represent the medical and psychological needs and social preferences of the person”. It also says: “Sufficient and accurate information should be provided on discharge to enable any providers of onward care and support to meet the needs of the person transferred to them.”
21. In Lincolnshire, they use a ‘care home trusted assessor’ approach. This is an agreement between the NHS, the Council’s adult social care team and care home providers for a third party (CareinLincs) to carry out a care needs assessment and create a care plan on behalf of care homes. In June 2022, CareinLincs completed Trusted Assessments over the phone due to the ongoing risk associated with COVID-19.

The pressure sore care and treatment

22. In 2014, the National Institute for Health and Care Excellence (NICE) produced ‘Clinical Guidance 179: Pressure ulcers: prevention and management’.
23. 1.3.1 states staff should “develop and document an individualised care plan for… adults who have been assessed as being at high risk of developing a pressure ulcer”.
24. 1.4.23 also states staff should discuss with adults about what dressing should be used. 1.4.24 also states: “Consider using a dressing for adults that promotes a warm, moist wound healing environment to treat category 2, 3 and 4 pressure ulcers.”
25. A category 2 pressure sore shows when the outer surface of the skin or the deeper layer of skin is damaged.

What happened

26. Following a fall, the Hospital Trust admitted Mr Y on 18 May 2022. Mr Y had pressure sores during his admission.
27. On 26 May, the Hospital Trust told the Council Mr Y needed equipment and support for his mobility to return home (a hospital bed and sit to standing aid). The Council shared that with Mr Y’s wife. She said Mr Y would self-fund his care and agreed to arrange that support privately.
28. After some confusion between Mr Y’s wife and the Hospital Trust about who was arranging his care package, on 13 June, the Council called Mr Y’s wife. Following a conversation about finances and arrangement fees, Mr Y’s wife asked the Council to source a package of care for Mr Y.
29. The next day, the Hospital Trust asked the Council to assess Mr Y’s needs. It said Mr Y could return home with a package of care.
30. By 16 June, the Council could not find a care agency to support Mr Y at home. So it told Mr Y’s wife it would fund an interim bed at a care home, while it arranged a package of care in his home.
31. On 17 June, CareinLincs completed a telephone assessment of Mr Y on behalf of The Old Rectory. The Trusted Assessment decided what support he needed.
32. Two days later, the Hospital Trust asked a Physiotherapist to review Mr Y’s mobility. He struggled to use his equipment to move from sitting to standing.
33. On 20 June, the Hospital Trust told the Council that Mr Y’s wife wanted to move him to a specific nursing home. The Council said The Old Rectory could meet Mr Y’s needs and the same day, the Hospital Trust discharged Mr Y to The Old Rectory. It did not refer Mr Y to the Community Trust for pressure sore support.
34. On arrival, The Old Rectory noted Mr Y had a category 2 pressure sore to the sacrum, and dressings to his chin and toes without dressings. He also had blistered and discoloured penis and testicles. The Old Rectory agreed to reposition Mr Y every two hours.
35. On 24 June, a District Nurse for the Community Trust came to assess Mr Y’s continence. The Old Rectory also asked the District Nurse to review his pressure sores. The District Nurse recorded the pressure sores, took photos and provided advice to The Old Rectory to support them.
36. On 26 June, an out of hours doctor reviewed Mr Y. He decided Mr Y was nearing the end of his life.
37. The next day, Mr Y was due to move home with support. But as Mr Y’s health worsened, the Council cancelled his care package and stayed at The Old Rectory.
38. On 29 June, a District Nurse reviewed Mr Y. They developed a care plan for Mr Y, applied dressings and took photos again.
39. On 4 July, a District Nurse reviewed Mr Y. They changed his dressings and repeated advice to The Old Rectory.
40. Mr Y moved to a nursing home the next day. He then died on 6 July.

The hospital discharge

41. I have reviewed the Hospital Trust’s medical and discharge records.
42. I consider the Hospital Trust missed an opportunity for a physiotherapist to reassess Mr Y’s mobility needs, before it discharged him. That was fault, and not in line with the National Discharge Guidance.
43. The Hospital Trust told me the result of that assessment would not have changed its decision to discharge Mr Y to The Old Rectory. It said The Old Rectory could meet Mr Y’s needs. I accept the Hospital Trust’s point, and The Old Rectory has told me it met his needs. So, on the balance of probabilities, I consider Mr Y would still have moved to The Old Rectory even if a physiotherapist reviewed Mr Y before discharge. However, the Hospital Trust missed an opportunity to better capture Mr Y’s mobility needs. The Old Rectory expected Mr Y to have greater mobility than he did, in line with the Trusted Assessment. The Hospital Trust should have paused the decision to discharge Mr Y and updated The Old Rectory about any change to Mr Y’s mobility. The Old Rectory would have been better placed to accept him. I can understand how that fault would have been distressing for Mrs X then.
44. The Hospital Trust has accepted this fault in its complaint response. It has also improved its service to ensure staff are aware they should complete outstanding assessments before discharging someone. I consider that has appropriately remedied the distress Mrs X suffered.
45. I also consider the Hospital Trust missed an opportunity to refer Mr Y to the Community Trust on discharge. That was fault.
46. Mr Y had pressure sores which needed treatment in the community. During my investigation, the Hospital Trust recognised that fault and accepted it should have referred Mr Y to the Community Trust for support.
47. If the Hospital Trust had made that referral, the Community Trust would most likely have triaged Mr Y among other patients, to decide when to review him following discharge. It is established best practice for district nurses to review patients between one and seven days after. In Mr Y’s case, the District Nurse reviewed Mr Y four days after the discharge. I cannot say, even on the balance of probabilities, if the Community Trust would have reviewed Mr Y sooner than it did. That has caused Mrs X uncertainty. She will not know if Mr Y would have received support for his pressure sores sooner, if not for its fault. The Hospital Trust should take action to remedy that injustice to Mrs X.

The decision to move to The Old Rectory

48. Mrs X disagrees with the decision to move Mr Y to The Old Rectory. But we cannot question that decision unless the Council and Hospital Trust acted with fault when making it.
49. I have reviewed the Council and Hospital Trust’s records during the discharge process.
50. During Mr Y’s admission, the Council and Hospital Trust both agreed Mr Y could move home on discharge with support and equipment.
51. The Council started searching for a care provider on 15 June. When it could not find one, the Council agreed to move him to The Old Rectory until it arranged a care provider.
52. I do not consider the Council acted with fault in how it decided to move Mr Y to The Old Rectory. The Council based its decision on:
• Mr Y being medically fit for discharge
• The lack of care providers able to support Mr Y at home
• The Old Rectory being able to meet Mr Y’s needs.
53. Once someone is medically fit to leave hospital, organisations should not delay discharging them. The longer people wait unnecessarily in hospital, there are higher risks of getting infection, falls and worse physical outcomes. The Hospital Trust had a responsibility to manage its hospital beds, once patients are medially fit for discharge. I consider the Council and Hospital Trust acted in line with the National Discharge Guidance here.
54. It was unfortunate the Council could not arrange a care provider for Mr Y at home. However, on the balance of probabilities, that care package of four calls a day would not have met Mr Y’s needs and would most likely have broken down. That was because Mr Y’s mobility and pressure care needs were greater than from the Trusted Assessment, which the Council based its decision making on. I have already found that was fault by the Hospital Trust, not the Council.
55. Overall, I consider The Old Rectory could support Mr Y’s needs, which it did until Mr Y’s family moved him to a nursing home. It was unfortunate due to the Hospital Trust’s fault, The Old Rectory were not better prepared to support him. I also cannot find The Old Rectory at fault for not expecting Mr Y’s health to get worse between 20 June and 5 July.

The pressure sore care and treatment

56. I have reviewed the Community Trust’s medical records.
57. I do not consider the Community Trust managed Mr Y’s pressure sores in line with the NICE guidance on 24 June 2022. It noted Mr Y had pressure sores to his penis, testicles and sacrum. However, it did not create a care plan for Mr Y or document what dressings he needed. That was fault. However, I am not persuaded that caused Mr Y any injustice. The photographs of Mr Y’s sores show Mr Y’s sores did not get worse from 24 to 29 June.
58. From 29 June onwards, I consider the Community Trust provided care and treatment for Mr Y’s pressure sores in line with the NICE guidance. It documented a clear plan to manage them, applied dressings and gave correct advice to The Old Rectory to support him. It provided barrier cream, recommended using slide sheets (to reposition Mr Y) and advised repositioning him every two hours. That was in line with established good practice.
59. I also consider The Old Rectory provided appropriate support for Mr Y’s pressure sores. The Community Trust’s records showed The Old Rectory repositioned Mr Y every two hours, applied barrier cream and used the slide sheets. If the Community Trust had concerns with The Old Rectory’s support, it would have record that.
60. I have found the Community Trust acted with fault on 24 June. That did not cause Mr Y an injustice, but it should take action to avoid similar fault to others.

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Action

61. Within four weeks, the Hospital Trust should apologise to Mrs X for the uncertainty caused by not referring Mr Y to the Community Trust on discharge.
62. Within eight weeks, the Hospital Trust should ensure relevant staff are aware of their responsibility to make referrals for patients who will need community support on discharge.
63. Within eight weeks, the Community Trust should ensure relevant staff are aware of their responsibility to complete care plans, and consider dressings, when they identify someone with pressure sores.
64. The organisations should provide us with evidence they have complied with the above actions.

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Decision

65. I find fault causing injustice. The organisations have agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman