Summary: The Ombudsmen found no fault by a Council and GP Practice in terms of the care provided to an elderly woman in hospital and a nursing home. The Ombudsmen found fault with the Trust’s failure to arrange a heart scan but are satisfied this did not have a significant impact on the woman’s care.

The complaint

1. The complainant, who I will call Mrs B, is complaining about the care and treatment provided to her mother, Mrs C, by Surrey County Council (the Council), Surrey and Sussex Healthcare NHS Trust (the Trust) and Moat House Surgery (the Practice). Mrs B complains that:

• The Trust and Council discharged Mrs C from hospital in October and December 2017 even though she was not sufficiently well.
• The Trust failed to provide proper treatment for Mrs C’s heart condition during her hospital admissions in 2017.
• The Trust failed to provide information to the family about Mrs C’s heart condition and her poor prognosis.
• The Practice failed to visit Mrs C when she became unwell during her time in a nursing home.
• Staff at a nursing home placement funded by the Council failed to arrange for Mrs C to be admitted to hospital when her condition deteriorated.

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The Ombudsmen’s role and powers

2. 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).
3. 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.
4. 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

5. In reaching this final decision, I considered information provided by Mrs B and discussed the complaint with her. I considered documentation provided by the Trust, Council and Practice, including the clinical records. I took clinical advice from a nurse, physician and GP. Furthermore, I took account of relevant legislation and guidance.
6. I also invited comments on my draft decision statement from Mrs B and the organisations she is complaining about and considered the responses I received.

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What I found

7. The Department of Health (DoH) produces guidance entitled Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate care (March 2010) (the ‘Ready to go guidance’). This is the core guidance on hospital discharge. It contains ten key steps for staff to follow during discharge planning, including:

• start planning for discharge or transfer before or on admission;
• identify whether the patient has simple or complex discharge and transfer planning needs and involve the patient and carer in your decision;
• involve patients and carers so that they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence.

8. A patient can be defined as clinically or medically stable if tests (such as blood tests and observations) are considered to be within the normal range for the patient. A patient is ‘fit for discharge’ when all relevant physiological, social, functional, and psychological factors have been taken into account. This can require a multidisciplinary assessment.

Social care assessment

9. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment of any adult who appears to need care and support. They must assess anyone, regardless of their finances or whether the council thinks they have eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the outcomes they want to achieve. It must involve the individual and where appropriate their carer or any other person they might want to be involved.

Nursing

10. The Nursing and Midwifery Council (NMC) produces guidance for nurses entitled The Code (the NMC Code). Sections 13.1 and 13.2 of the NMC Code set out the importance of accurately identifying, observing and assessing the signs of worsening mental and physical health in a patient. The NMC Code also says nurses should make a timely referral to another practitioner “when any action, care or treatment is required.”

General Practitioners

11. The General Medical Council (GMC) is the regulatory body for GPs in England. The GMC produces guidance entitled Good Medical Practice. This guidance says a GP must:

• “adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient
• promptly provide or arrange suitable advice, investigations or treatment where necessary
• refer a patient to another practitioner when this serves the patient’s needs.”

Key facts

12. Mrs C had coronary artery bypass surgery in February 2017. This is a surgical procedure to divert blood around narrow or clogged arteries to improve blood flow to the heart.
13. Mrs C underwent a prolonged period of recovery in hospital. She was eventually discharged home in August 2017 with a privately funded package of care.
14. Following a fall at home, Mrs C was admitted to hospital again in September 2017. She remained there until 3 October, when she was discharged home with the same package of care.
15. However, Mrs C was admitted again later that day as she reported feeling generally weak. She was transferred to an elderly ward for assessment of her mobility needs.
16. Mrs C remained in hospital until December 2017. Further clinical investigations revealed no significant concerns. Nevertheless, the multidisciplinary team responsible for her care felt she would benefit from the extra support provided within a nursing home environment.
17. The Council arranged a nursing home placement and Mrs C was discharged on 22 December.
18. Mrs C became unwell in early January 2018. Nursing home staff reported concerns to the Practice on 8 January and a GP prescribed a course of antibiotics. A GP visit was scheduled to take place on 10 January.
19. However, Mrs C’s condition deteriorated before this visit took place. She was admitted to hospital where she died on 10 January.

Analysis

Discharge – October 2017

20. Mrs B complained that the Trust inappropriately discharged Mrs C from hospital in October 2017. Mrs B said her mother was not medically fit for discharge and required readmission the same day.
21. The Trust said Mrs C was considered clinically fit for discharge following treatment for a urinary tract infection and an acute kidney injury. The Trust said the team treating Mrs C felt she may benefit from additional physiotherapy support within an inpatient rehabilitation placement to improve her mobility. However, the Trust said Mrs C was keen to return home and declined this option.
22. The clinical records show Mrs C was constipated on admission to hospital in September 2017.Clinicians undertook a Computed Tomography (CT) scan of her chest, abdomen and pelvis to rule out any underlying conditions.
23. Mrs C told clinicians she had fallen as a result of her legs giving way. As Mrs C was experiencing some drooping of her left foot, the Trust also arranged a Magnetic Resonance Imaging (MRI) of Mrs C’s brain.
24. These scans revealed no significant abnormalities.
25. The records show Mrs C had an acute kidney injury. The treating clinicians treated her with intravenous fluids and temporarily withdrew medications that could impair her kidney function. Blood tests taken on 2 October showed Mrs C’s kidney function had returned to normal.
26. The tests undertaken on admission also revealed that Mrs C was suffering from a urinary tract infection. Clinicians successfully treated this with a course of antibiotics.
27. Mrs C was also assessed by the Trust’s therapy team. The assessment showed Mrs C could transfer from her bed with assistance from one person and was able to mobilise with similar assistance and the use of her walking frame. As Mrs C declined a transfer to an inpatient rehabilitation unit, the Trust arranged ongoing physiotherapy for her at home. The Trust also contacted Mrs C’s care provider to arrange for her private package of care to recommence on discharge.
28. The clinical evidence shows Mrs C was medically stable at the point of discharge on 3 October. There was no clinical reason for her to remain in hospital, therefore.
29. The Trust’s therapy team felt Mrs C would benefit from further assessment of her mobility needs but she was unwilling to transfer to a rehabilitation placement for this to take place.
30. In the circumstances, I consider the decision to discharge her home with her existing package of care and additional physiotherapy support in the community to have been appropriate and in keeping with good clinical care. I found no fault by the Trust in this regard.
31. I note Mrs B’s concern that Mrs C’s readmission later that day suggests she should not have been discharged in the first place. However, the clinical evidence does not support this view.
32. When Mrs C attended hospital again later on 3 October, she reported feeling generally weak. In addition, her husband noticed she had reduced urinary output.
33. Clinicians noted Mrs C appeared alert and chatty. Staff took observations and blood tests. The results of these were normal and showed Mrs C was no longer suffering from a urinary tract infection. The clinical records show Mrs C was medically stable at that time and she did not require admission for clinical treatment. Rather, Mrs C was admitted for further assessment and support from the Trust’s therapy team.

Cardiology care

34. Mrs B complained that the Trust failed to provide appropriate treatment for Mrs C’s heart condition during her hospital admissions in 2017.
35. The Trust said Mrs C had no specific cardiac symptoms at the time of her admissions between September and December 2017 and did not require input from the cardiology team.
36. The clinical records show Mrs C underwent heart surgery at another hospital in February 2017, having suffered a heart attack. She was transferred to the care of the Trust in March 2017 for period of recovery.
37. In August 2017, the Trust’s cardiology team reviewed Mrs C at an outpatient appointment. The reviewing cardiologist noted Mrs C’s wound had healed well. He found she had no chest pains and was experiencing no breathing problems or heart palpitations. The cardiologist arranged for a follow-up appointment to take place in four to five months. He also requested an echocardiogram (a detailed heart scan) be taken prior to the appointment.
38. In the meantime, a cardiothoracic surgeon from the hospital that carried out the operation reviewed Mrs C again in September 2017. He also found Mrs C’s wound had healed nicely and that her chest was clear with normal heart sounds. The surgeon discharged Mrs C back to the care of the Trust.
39. The echocardiogram requested by the cardiologist was due to take place in November 2017. However, this was erroneously booked as an outpatient appointment. As Mrs C had by this point been readmitted to hospital, the scan did not take place. This was fault by the Trust.
40. Nevertheless, there is no evidence in the clinical records relating to Mrs C’s admissions between September and December 2017 to suggest she was suffering from ongoing cardiac problems or symptoms that required input from the Trust’s cardiology team. The evidence shows the focus of Mrs C’s care was on supporting her rehabilitation through input from the therapy team.
41. I am not persuaded the failure to carry out an echocardiogram had a significant impact on Mrs C’s care, therefore.

Communication

42. Mrs B complained that the Trust failed to provide information to the family about Mrs C’s heart condition and her poor prognosis. She said this meant the family was unable to make an informed decision about her end-of-life care.
43. The Trust said the elderly care consultant responsible for Mrs C’s treatment had discussed her care with the family several times. The Trust said the consultant explained that Mrs C was generally frail and would be at risk of becoming unwell.
44. The Trust’s records show the clinicians did discuss Mrs C’s care with her family throughout her admissions between September and December 2017. These discussions generally focused on Mrs C’s potential for rehabilitation and discharge arrangements. The clinical team established that Mrs C’s husband felt unable to care for her at home and it was agreed a nursing home placement would be appropriate.
45. The clinical records show Mrs C had long-term ischaemic heart disease. This placed her at greater risk of cardiac problems. However, there was no indication Mrs C was suffering from any significant cardiac symptoms during her admissions in 2017, nor any evidence to suggest there was a high risk of death at that time. Indeed, the treating clinicians were satisfied Mrs C was medically fit for discharge from 12 October.
46. In this clinical context, there was no basis for the clinical team to discuss end of life care with Mrs C’s family. I found no fault by the Trust on this point.

Discharge – December 2017

47. Mrs B complained that the Council and Trust failed to appropriately plan and manage Mrs C’s discharge from hospital in December 2017. Mrs B said this meant Mrs C was not sufficiently well for discharge and that she was discharged to an unsuitable nursing home placement that was not prepared for her arrival.
48. As explained above, Mrs C was readmitted to hospital on 3 October. She reported feeling unable to cope at home and had reduced urinary output. However, tests revealed no evidence of infection at that time.
49. Following a discussion with Mrs C’s family on 11 October, the treating consultant decided she was fit for discharge. However, she agreed to transfer Mrs C to a ward for a limited period of rehabilitation and support from the therapy team.
50. The notes made by the therapy team show Mrs C was often unwilling to engage in therapy and preferred to remain in bed. The clinical team continued to monitor Mrs C throughout her admission. The notes show she remained stable and medically fit for discharge.
51. Trust staff spoke to Mrs C and her family about her preferred discharge destination. Initially, Mrs C was noted to be keen to return home. However, her husband reported concern that he would be unable to cope given Mrs C’s problems mobilising and need for continence care.
52. A nurse assessor from the local Clinical Commissioning Group assessed Mrs C to determine whether she would be eligible for Continuing Healthcare (CHC) funding (this is when the NHS funds the care of a patient with primary health needs). The assessment concluded Mrs C was not eligible for full CHC funding.
53. A Council social worker carried out a social care assessment and found Mrs C had eligible social care needs and required assistance with all activities of daily living. Mrs C and her family agreed her care needs could best be met in a residential placement and the Council agreed to fund this.
54. On 12 December, the Trust transferred Mrs C to an intermediate care ward while arrangements were made for her discharge.
55. The Council arranged for a residential home to assess Mrs C on 14 December. However, the placement concluded it would be unable to meet Mrs C’s needs as she wished to remain in bed and was unwilling to mobilise.
56. The Council subsequently identified two possible nursing home placements for Mrs C that were willing to accept her at the social care rate. Mrs B visited both placements and the records show she was not satisfied with either.
57. However, the Council explained that the hospital was facing significant bed pressures and that, if a nursing home had been identified that could meet Mrs C’s needs, discharge would need to be arranged as soon as possible. The Council also explained that Mrs C would be at increased risk of infection if she remained in hospital.
58. Mrs C’s family agreed to a transfer to one of the suggested nursing homes. A manager from the nursing home assessed Mrs C on 22 December and concluded it would be able to meet her needs. Mrs C was transferred to the nursing home later that day.
59. The Ready to go ‘guidance’ emphasises the importance of comprehensive discharge planning. In order for a patient to be discharged, they must be considered medically stable by the treating clinicians. However, the decision to discharge must also consider “all relevant physiological, social, functional, and psychological factors have been taken into account.” Discharge planning should begin as soon as a patient is admitted.
60. The clinical records show Mrs C was considered to be medically stable from 12 October. Mrs C was reviewed regularly by the treating clinicians throughout her admission. Tests and examinations undertaken during this time revealed no acute illness requiring inpatient hospital treatment. Similarly, there is no evidence in the records to suggest Mrs C required ongoing cardiology care. I am satisfied Mrs C was medically stable, therefore.
61. The records show a social worker carried out a comprehensive assessment of Mrs C’s social care needs in December 2017. This assessment found Mrs C required extensive support with daily tasks, such as preparing food and mobilising to the toilet. The Council therefore agreed to fund Mrs C’s residential placement.
62. The records also contain evidence of correspondence between professionals involved in Mrs C’s care and her family regarding her care needs and discharge arrangements. The views of Mrs C, her husband and the family were clearly recorded and taken into account.
63. In summary, the evidence shows Mrs C was ready for discharge in December 2017 following comprehensive assessment of her health and social care needs and input from her family. In my view, the discharge was handled appropriately and in accordance with the ‘Ready to go’ guidance. I found no fault by the Council or Trust in this regard.
64. I appreciate Mrs B felt the discharge process was rushed and the family was not given enough choice in terms of residential placements. However, I note that only a limited number of placements could meet Mrs C’s needs as she was reluctant to mobilise and preferred to remain in bed. This limited the available choices.
65. The Council was correct to point out that extended hospital admission carries increased risk of infection in elderly and frail patients. In my view, it was in Mrs C’s best interests for discharge to be arranged as soon as a suitable placement was found, albeit I understand Mrs B would have preferred more choice.

Deterioration and GP care

66. Mrs B complained that the Practice failed to visit and review Mrs C when she became unwell during her time in the nursing home. Mrs B said the Practice instead prescribed antibiotics over the telephone. Mrs B also complained that staff at the nursing home failed to take action when Mrs C’s condition worsened. Mrs B said she asked nursing home staff to call an ambulance but was told this was not necessary as a doctor from the Practice would be reviewing Mrs B the following day.
67. The records suggest Mrs C was initially well on transfer to the nursing home in December 2017. She was noted to be sleeping well and generally taking fluids, although she sometimes refused meals.
68. The nursing home records show Mrs C became unwell in on 3 January 2018 and was noted to have vomited. Nurses took clinical observations. These revealed no abnormalities.
69. Mrs C continued to vomit sporadically over the following days. However, further clinical observations taken on 6 January were normal.
70. On 7 January, when Mrs C remained unwell, nurses at the nursing home arranged a urine dipstick test. This returned a positive result, which was suggestive of a urinary tract infection.
71. The nursing home contacted the Practice the following day to discuss Mrs C’s care.
72. The GP noted “dipstick positive, vomiting occasionally, not dehydrated”. The GP concluded Mrs C was likely suffering from a urinary tract infection. He prescribed a course of antibiotics and advised the nursing home to maintain fluids for Mrs C to prevent dehydration. The GP also advised nursing home staff to contact the Practice again if Mrs C’s condition deteriorated.
73. The nursing home contacted the Practice the following day as Mrs C remained unwell. A GP noted “Occ vomiting for a few days. Started on [antibiotics] this afternoon.” The GP advised the nursing home to attempt a urine test and arranged blood tests for Mrs C. A GP was due to visit Mrs C the following day.
74. However, on the morning of 10 January, nursing home staff found Mrs C unresponsive in her room. Staff called an ambulance and Mrs C was taken to hospital where she was found to have suffered a heart attack. She died later that day.
75. The clinical records show that, when Mrs C first became unwell, nursing home staff monitored her and took clinical observations. These tests returned normal results. However, when Mrs C remained unwell, nursing home staff took a dipstick test and contacted the Practice for advice. Staff continued to monitor Mrs C and took further observations. This was in accordance with the NMC Code.
76. I note Mrs B feels a GP should have visited Mrs C when the nursing home reported she was unwell. However, in my view, the GP carried out an adequate consultation over the telephone on 8 January and there was no clinical reason for a visit.
77. The GP took an appropriate clinical history from the nurses at the nursing home. Mrs C’s recent history of vomiting, along with the positive dipstick test and more general history of infections, was highly suggestive of a urinary tract infection.
78. There is nothing in the clinical records of either the nursing home or Practice to suggest Mrs C’s presentation had changed or that her condition had deteriorated when nursing home staff contacted the Practice again on 9 January. On this basis, there was no indication for an urgent GP visit.
79. Mrs C had only just started her course of antibiotics and they would have had little chance to take effect by this point. The Practice therefore arranged further testing while Mrs C completed the course of antibiotics.
80. The evidence shows the Practice appropriately assessed Mrs C on 8 January and made the decision to treat her with antibiotics within the nursing home environment pending a routine visit on 10 January. This was in keeping with GMC guidance.
81. Mrs C did have long-term ischaemic heart disease. This placed her at greater risk of heart attack. However, the clinical records do not suggest Mrs C was suffering from any significant cardiac problems in January 2018 that would have indicated a heart attack was imminent at that time.
82. In my view, the care provided to Mrs C by the nursing home and Practice was in accordance with clinical guidelines and I found no fault here.

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Final decision

83. I found no fault by the Council or Practice in terms of the care provided to Mrs C in 2017 and 2018.
84. I found fault by the Trust with regards to the failure to arrange an echocardiogram for Mrs C. However, I am satisfied this did not have a significant impact on her care.
85. I have now completed my investigation on this basis.

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Parts of the complaint that I did not investigate

86. Mrs B also complained about difficulties with Mrs C’s transfer from hospital to the nursing home and the fact the nursing home was not prepared for her arrival.
87. The Council addressed these matters in its response to Mrs B’s complaint. The Council accepted transport had been booked for Mrs C for between 4.00pm and 7.00pm, but that Mrs C had been ready for transfer at 2.30pm. The Council apologised for this.
88. The Council acknowledged the nursing home was not ready for Mrs C when she arrived and that this meant there was a delay before she could be put to bed. The Council apologised for this.
89. In my view, the Council’s response to these issues was reasonable and proportionate. I did not include these matters in my investigation as I considered it unlikely the Ombudsmen would be able to add significantly to this response.

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Investigator's decision on behalf of the Ombudsman