Summary: Wirral University Teaching Hospital NHS Foundation Trust acted with fault by not including Mrs X’s medication changes to her discharge paperwork. The Trust has remedied the injustice to Mrs X’s son, Dr Y. Also, Liscard Group Practice and Leighton Court Care Home did not contribute to a delay restarting Mrs X’s medication.

The complaint

1. The complainant, whom I shall call Dr Y, complains about the actions of the Wirral University Teaching Hospital NHS Foundation Trust (the Trust), Leighton Court Care Home (the Care Home - owned by HC-One and funded by Wirral Metropolitan Borough Council) and a named GP (the GP) at Liscard Group Practice (the Practice) on behalf of his mother, Mrs X (deceased).
2. Dr Y says the Trust should have consulted with his mother’s outpatient cardiac specialist when she was an inpatient to assess any potential impact on discharge. Also, it should have included changes to his mother’s medications on the discharge transfer paperwork when she moved to the Care Home.
3. Dr Y says the GP should not have delayed restarting his mother’s medication after 17 May 2019 which coincided with a weekend. The Trust’s cardiac specialist had specifically requested those be restarted on 17 May.
4. Dr Y says the Care Home should have chased the GP after 17 May to restart those medications, rather than wait for instructions. Also, he says when his mother suffered a blackout three days later, she should not have been left alone at that time.
5. Dr Y also says the Trust did not communicate medication changes to him during his mother’s admission.
6. Dr Y says he is left with a continuing sense of uncertainty. He does know if things were done differently between 17 and 20 May 2019, whether the outcome may have been different for his mother. He says the events were and remain distressing for him. Also, his father had to sell his flat to pay for care home fees after Mrs X died (who was his carer).
7. Dr Y would like the organisations to make meaningful changes to ensure similar failings do not happen to others. Also, he would appreciate a financial remedy to recognise the financial impact to his father, and for the distress and uncertainty Dr Y and the wider family suffered.

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What I have investigated

8. I have investigated paragraphs 1 to 4 above. The final section of the statement contains my reasons for not investigating paragraph 5.

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The Ombudsmen’s role and powers

9. 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)
10. 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).
11. The Ombudsmen provide a free service but must use public money carefully. They may decide not to start or continue with an investigation if they believe it is unlikely they could add to any previous investigation by the bodies.
12. When investigating complaints, if there is a conflict of evidence, the Ombudsmen 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. 
13. 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

14. I read the papers submitted by Dr Y and I discussed the complaint with him. I considered the organisations comments about the complaint and the supporting documents they provided.
15. Dr Y and the organisations had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Key facts

16. The Trust admitted Mrs X after she fell at home on 2 May 2019. Mrs X was already under a consultant cardiologist (the Cardiologist) as an outpatient. During the admission, the Trust decided to stop Mrs X’s medications including metformin and digoxin. She had a successful hip operation.
17. On 16 May, the Trust discharged Mrs X to the Care Home. The Trust’s discharge paperwork did not include Mrs X’s changes to her medications. Mrs X later told Dr Y she was not getting digoxin.
18. The next day, Dr Y wrote to the Care Home and the GP with concerns about Mrs X’s medications. Later that day, the GP reviewed Mrs X at the Care Home. Dr Y was present. The GP noted Mrs X had an irregular pulse and asked the Care Home to check her pulse and blood pressure daily. If she developed a rapid rate, the Care Home should contact the GP. The GP told Dr Y that because Mrs X had a slow pulse rate, he would not restart digoxin.
19. Later that day, a Cardiac Specialist Nurse (working for the Cardiologist) told the Care Home that it should restart Mrs X’s digoxin and metformin. The Care Home referred the Cardiac Specialist Nurse to the GP to prescribe them.
20. On 20 May, the Cardiac Specialist Nurse emailed the GP on behalf of the Cardiologist. The Cardiologist wanted the GP to restart digoxin and metformin (but only if Mrs X’s renal function was stable). The GP arranged a prescription to be delivered later that day. However, before the Care Home received the prescription, Mrs X collapsed. Mrs X told staff she was unsure if she fell or fainted and recalled feeling light-headed. No one witnessed Mrs X collapse. She went back to the Trust where she received palliative care and later died from aortic stenosis. That is when blood flow from the heart is restricted.

Analysis

Consultation with the outpatient consultant

21. In response to my investigation, the Trust said it is not routine to discuss a patient with their outpatient consultant. In Mrs X’s case, the Trust said it had inpatient cardiology experts who could make decisions about changing long-term medication. It was not necessary to consult Mrs X’s outpatient consultant.
22. I understand why Dr Y felt the Trust could have understood Mrs X better by consulting with the Cardiologist. However, I do not consider the Trust acted with fault by not consulting with the Cardiologist during her admission. The inpatient staff could appropriately consider Mrs X’s acute condition and stop her medications. When the Trust discharged Mrs X, it was aware the Cardiologist planned to review her in June. I consider that approach was appropriate. Therefore, I will not take any further action.

Medication changes missing from the discharge paperwork

23. The National Institute for Health and Care Excellence (NICE) issued clinical guideline known as Transition between inpatient hospital settings and community or care home settings for adults with social care needs in 2015.
24. Section 1.5.15 says: “The discharge coordinator should ensure that the discharge plan takes account of the person’s social and emotional wellbeing, as well as the practicalities of daily living. Include...information about the person’s medicines”.
25. NICE also issued clinical guidance known as Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes in 2015.
26. Section 1.2.1 says: “Organisations should ensure that robust and transparent processes are in place, so that when a person is transferred from one care setting to another:
• The current care provider shares complete and accurate information about the person’s medicines with the new care provider and
• the new care provider receives and documents this information and acts on it.”
27. Section 1.2.3 says: “Health and social care practitioners should share relevant information about the person and their medicines when a person transfers from one care setting to another. This should include...changes to medicines, including medicines starting or stopped, or dosage changes, and reason for the change”.
28. In response to Dr Y’s complaint, the Trust said it signed off the discharge summary two days before it discharged Mrs X. Therefore, the discharge summary to the Care Home did not include information about Mrs X’s medication changes. The Trust confirmed the person who signed the discharge summary did so before they went on annual leave. While that person wanted to provide a well written summary, the Trust accepted that was premature and apologised. The Trust said staff are aware they should only sign discharge summaries when discharging the patient.
29. I consider the Trust did not complete Mrs X’s discharge summary in line with the NICE guidance above. That was fault, which would have caused Dr Y confusion. Dr Y also suffered time and trouble having to make two separate complaints to understand what happened. The Trust has appropriately apologised to Dr Y and ensured relevant staff have learnt from that fault. I consider the Trust has remedied the injustice Dr Y suffered. Therefore, I will not take any further action.

Restarting Mrs X’s medication

30. In response to my investigation:
• The Trust told me it decided not to restart Mrs X’s medications until the Cardiologist had reviewed her. The Cardiologist also told me the decision to stop Mrs X’s medications during the admission was appropriate.
• The Practice told me the Cardiac Specialist Nurse first requested Mrs X restart medications on 20 May 2019 (by email).
• The Care Home told me it referred the Cardiac Specialist Nurse to the GP on 17 May to restart medications. Between 17 and 20 May, it followed the GP’s instruction to check Mrs X’s pulse.
31. The Care Home records show the Cardiac Specialist Nurse first asked to restart medications on 17 May. After the Care Home referred them to the Practice, the Cardiac Specialist Nurse took three days to confirm that to the Practice by email. I cannot say that three-day delay was fault by the Practice. The Practice records show that on receiving the Cardiac Specialist Nurse’s email (on 20 May), it quickly prescribed digoxin. That was good practice.
32. I also cannot agree the Care Home was at fault for not chasing the Practice. Three days earlier, it appropriately referred the Cardiac Specialist Nurse to the Practice. The Care Home cannot administer medications without a prescription. Instead, I consider it appropriately followed the GP’s instruction to check Mrs X’s pulse. The Care Home did not need to contact the GP again because Mrs X’s pulse did not cause any concern.
33. In any event, the Cardiologist told me he did not consider that prescribing the medications sooner than 20 May would have made a difference to Mrs X. Mrs X’s prognosis was already poor, coupled with the fact she had only recently had hip surgery. Therefore, even if I agreed the Practice and/or Care Home acted with fault, I would not likely consider there would be an injustice to Mrs X. Therefore, I will not take any further action.

The Care Home’s lack of care and support

34. Mrs X’s care and support plan stated that: “Currently she is to transfer with two people... [Mrs X] will not walk unaided. [Mrs X] is able to use the call bell unaided”.
35. On 20 May, the Care Home’s daily record on show that Mrs X was “assisted with hygiene needs transferred safely [sic]...4.40: found on floor at 4.40 following being returned from toilet by a carer. I found [Mrs X] lying on her lt [left] side by her chair, stated she had fainted”.
36. In response to my investigation, the Care Home told me that at 4.35pm a Healthcare Assistant supported Mrs X to the toilet and then returned her to her chair. Five minutes later, a Nurse found Mrs X on the floor.
37. I have not seen any evidence from the time to confirm the Healthcare Assistant supported Mrs X five minutes before she fell. I do not doubt the Healthcare Assistant supported Mrs X shortly before she fell, but they did not record what time they supported Mrs X to the toilet. I do not consider that was fault, but it would have been better practice for the Healthcare Assistant to record what time they supported Mrs X on 20 May. Overall, I consider Mrs X most likely fainted/fell after the Healthcare Assistant returned her returned to the toilet. I do not consider Mrs X fainted/fell trying to get to the toilet.
38. However, the Care Home did not support Mrs X in line with her care plan. Only one person (the Healthcare Assistant) supported Mrs X from the toilet. Mrs X’s care plan clearly stated two people should support her. That was fault. But I am not persuaded that caused Mrs X any injustice. When she fainted, the Healthcare Assistant had safely returned Mrs X to her chair from the toilet. I cannot see what more the Care Home could have done to avoid Mrs X fainting on 20 May. Therefore, I will not take any further action.

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Final decision

39. I consider the Trust acted with fault by omitting medication changes from the discharge paperwork. That caused Dr Y confusion, but I am satisfied the Trust has already remedied that injustice to him.
40. I consider the Care Home appropriately referred the Cardiac Specialist Nurse to the Practice to prescribe medications to Mrs X.
41. I also consider the Care Home did not act support Mrs X in line with her care plan on 20 May. However, there was no injustice to Mrs X.

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Parts of the complaint that I did not investigate

42. Dr Y says the Trust should have communicated changes to Mrs X’s medications during her admission. In response, the Trust apologised if it did not clearly communicate those changes to him. I consider the Council has appropriately apologised for its lack of communication. I do not consider an investigation by the Ombudsmen could provide anything further for Dr Y on this issue.

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Investigator's decision on behalf of the Ombudsman