Summary: We investigated a complaint about a hospital discharge and care provided to Ms Y in a care home. We found fault with the Trust, who did not initially involve Mrs X with the discharge planning for Ms Y in March 2021. The Trust has apologised to Mrs X and made service improvements to ensure the fault does not happen again. We consider this to be enough to remedy the injustice to Mrs X. We also found fault with the Health Centre, who did not speak to Mrs X before prescribing antidepressants to Ms Y. This caused Mrs X unnecessary worry and distress. The Health Centre agreed to apologise and make service improvements to remedy this injustice. We found no fault with the Council.

The complaint

1. Mrs X complains about the care provided to her mother, Ms Y, by Plymouth Hospitals NHS Trust (the Trust), Venn House residential home (the Care Home) acting on behalf of Devon County Council (the Council) and Tavyside Health Centre (the Health Centre). Specifically, she complains:
• The discharge team did not contact her during her mother’s discharge planning from hospital on 18 March 2021.
• The discharge planning by the Council and the Trust for her discharge on 29 March 2021 was inadequate. Mrs X says staff did not consider the difference in her mother’s mobility on admission to hospital and on discharge.
• The care at the Care Home was inadequate, staff failed to act when her mother’s health began to decline.
• Care Home staff did not recognise signs of dehydration or sepsis.
• Ms Y’s doctor, from the Health Centre, did not to visit her after Mrs X told them she was ill.
• Ms Y’s doctor did not tell Mrs X she had been put on antidepressants.
2. Mrs X feels her mother’s case has highlighted how vulnerable dementia patients are. She says her mother’s health declined significantly; she has not walked again. Mrs X has Lasting Power of Attorney (LPA) for her mother’s health and welfare. She feels she has not been able to fulfil her legal and moral duties because of lack of communication around treatment choices, changes to or new prescriptions and no response to raised concerns.
3. Mrs X wants the organisations to accept they failed to provide suitable care and did not properly consult with the holders of LPA, despite her mother’s lack of capacity. Mrs X wants to know there have been changes and if not, she wants service improvements to ensure others do not have the same experience.

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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 a single team has considered these complaints acting for 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 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 acts to stop the same mistakes happening again.
7. The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
8. 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

9. I considered the complaint Mrs X made to the Ombudsmen and information she provided by email. I also considered the information the Council, the Trust and the Health Centre provided in response to my enquiries.
10. I shared a confidential draft with Mrs X, the Council, the Trust and the Health Centre which explained my provisional findings and invited their comments. I considered the comments I received before making a final decision.

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What I found

Background

11. Ms Y was 85 years old at the time of the events under investigation. She had Alzheimer’s Disease and needed help with most aspects of her daily life. She did not have capacity to decide about her care and support needs. Mrs X held a LPA for Ms Y’s health and welfare so she could be involved in decisions about what should happen with Ms Y’s care and health needs.
12. Ms Y went into hospital on 11 March with an “exacerbation of her asthma” and she also received antibiotics for an unrelated infection.
13. Ms Y lived with someone, but Mrs X worried they could not support Ms Y if she went back home. She feared Ms Y would be back in hospital again soon and so this was not the best choice.

Complaints about discharge planning in March 2021

14. Mrs X complains the discharge team did not contact her during discharge planning of her mother from hospital in March 2021. Mrs X also feels the discharge planning by the Council and the Trust was inadequate. Mrs X says staff did not consider the difference between how much her mother could move around on admission to hospital and at discharge.
15. Ms Y went into hospital on 11 March 2021. She saw a physiotherapist on 12 March. Her notes state Ms Y was safe to move around with supervision and guidance, but it was unclear what her baseline was as due to Ms Y’s dementia, she could not give them her history. Ms Y’s records also note on 12 March “[Mrs X] would like to be contacted prior to discharge … agreed this is reasonable”.
16. Ms Y had another mobility assessment on 15 March. The notes show Ms Y told the physiotherapist she lives in a three-storey house with stairs and uses a stick in the house. The clinician noted her records show she lived in a flat with elevator access. The assessment noted she could move 25 metres independently, without aids, and return to her chair. It added she was still short of breath and still did not know her own baseline, but the clinician believed based on her file notes she was at the same level as she was at home before admission. A separate note on the same date says both Ms Y’s daughters hold LPA for health and welfare.
17. On 17 March, Ms Y was feeling better and doctors said she was medically fit for discharge home with an asthma management plan.
18. Mrs X contacted the ward again on 18 March because she was unhappy with the lack of contact and wanted an update. Staff “apologised to [Mrs X] for lack of communication, explained that I was talking to [Ms Y’s partner]… [Mrs X] was frustrated that discharge plan was not through her, she holds the LPA and has raised multiple safeguarding concerns in the past.”
19. Also on 18 March, Mrs X raised a safeguarding concern about her mother going home. She worried Ms Y would not remember to take her medication and she would need a readmission to hospital. Ms Y’s discharge was held until professionals could look at these issues.
20. On 21 March, Mrs X contacted the ward again to ask for an update. She spoke to the discharge co-ordinator and explained she had seen some care homes which she liked for her mother and wanted to know the next steps. Ms Y remained stable on a ward.
21. On 26 March, the discharge co-ordinator contacted Mrs X to discuss Ms Y’s discharge plans. Mrs X said she was happy for the Trust to discharge her mother to a care home for a short time and gave the Care Home as her preferred choice. The Trust agreed to contact them to see if they could meet Ms Y’s needs.
22. The Care Home confirmed it could care for Ms Y and she was discharged from hospital on 29 March.
23. The Trust’s discharge policy states “Discharge from hospital is a patient centred process that requires the collective contributions of various agencies and professional disciplines. It should be a planned, coordinated and systematic process with effective communication throughout. Individuals concerned and their carer(s) should be involved at all stages, and regular reviews and updates should take place to keep them fully informed.”
24. The Trust knew from 12 March Mrs X wanted contact about her mother’s care, and on the 15 March the notes confirm it knew she held LPA yet staff did not update her at first. This is fault.
25. In its complaint response of 15 July 2022, the Trust accepted it did not contact Mrs X at all stages during the discharge process for Ms Y. It apologised to Mrs X and said it had “reminded the medical, nursing and discharge team on [the] ward of the importance of checking patient medical records to ensure communication is undertaken with the correct person”.
26. Mrs X was frustrated with the Trust and had to contact them to get updates and ensure her mother’s discharge planning was suitable. This is an injustice to her which the Trust could have avoided had it contacted her suitably.
27. The Parliamentary and Health Service Ombudsmen’s Guidance on Remedies says, “where maladministration or poor service has led to injustice or hardship, the public body responsible should take steps to provide an appropriate and proportionate remedy.” It adds “public bodies should promptly identify and acknowledge maladministration and poor service and apologise for them.” The Trust has accepted its mistake, apologised to Mrs X and taken action to ensure it does not happen again. I consider this a suitable remedy for the identified fault and injustice caused to Mrs X.
28. I have not seen any evidence Ms Y’s mobility was different from when she went into hospital to when she left. She had two assessments before she was declared medically fit for discharge. Both assessments refer to it being difficult to prove her baseline due to cognition issues but note she could move around independently with supervision. Her medical history notes at home she used a stick.
29. I therefore find no fault with the actions of the Trust in assessing her mobility. Clinicians assessed her mobility level, admitted the difficulties in showing a baseline and recorded her movements which were the same as those before she went into hospital. As there was no cause for concern at that time, no further action was needed.
30. Mrs X explained Ms Y could not move around as she had before admission and she could no longer walk independently, I understand why this would be concerning. However, Ms Y became very unwell in the Care Home and needed to go back into hospital for treatment. I cannot separate any impact this later illness may have had on her mobility as it immediately followed.
31. In summary, I found fault with the Trust’s communication with Mrs X during the discharge planning for her mother. The Trust accepted this and provided a suitable remedy for the injustice she experienced. I have found no fault with the Trust’s assessment of Ms Y’s mobility while she was in hospital in March 2021.

Complaints about care given at the Care Home

32. Mrs X complains the care provided to her mother at the Care Home was inadequate. She feels staff should have done more when her mother’s health began to decline, and staff did not recognise signs of dehydration or sepsis.
33. Mrs X went to the Care Home on 29 March 2021 and remained there until 23 April. She became very unwell and needed to go back into hospital with an unknown cause of infection. The hospital treatment she received indicates she had clostridium difficile, also known as C. diff, which is a type of bacteria that can cause a bowel infection and sepsis, from pneumonia.
34. Mrs X raised a safeguarding concern to the Council about her mother’s care at the Care Home on 27 April. A council must enquire if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse.
35. The Council did a full safeguarding investigation of Mrs X’s concerns and told her in August it found no evidence of neglect. The Council closed the enquiry in September.
36. The Care Quality Commission (CQC) is the independent regulator of health and social care in England. Before a care provider can carry out any of the activities that the CQC regulate, they must be registered and satisfy the CQC it will be able to meet several legal requirements, including their fundamental standards. The CQC monitor and inspect care homes continuously to ensure care being provided is safe, effective, caring, responsive and well-led.
37. The CQC provide a rating to each care home based on its assessment of evidence it gathers during an inspection on key lines of enquiry. Venn House is rated as ‘Good’ by the CQC in its last two inspections in 2019 and 2022.
38. The CQC Fundamental Standards are the standards below which a providers’ care must never fall. They were established to protect the rights of patients. These standards build on government legislation.
39. I have reviewed Ms Y’s care records from the Care Home alongside the guidance for care homes, the legislation and the CQC’s Fundamental Standards.
40. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 12 emphasises the importance of working with others and sharing information; “where responsibility for the care and treatment of service users is shared with, or transferred to, other persons, working with such other persons, service users and other appropriate persons to ensure that timely care planning takes place to ensure the health, safety and welfare of the service users.” Ms Y’s records show staff sought advice from Ms Y’s doctor on several occasions when they were unsure how best to manage her care.
41. Ms Y did not have capacity to understand what care she needed, and Mrs X held LPA for her health and welfare. Regulation 9 states providers “must make sure that they take into account people’s capacity and ability to consent, and that either they, or a person lawfully acting on their behalf, must be involved in the planning, management and review of their care and treatment.” Ms Y’s records show staff were concerned about her decreasing ability to understand simple instructions and sought advice from Ms Y’s doctor about this. When Mrs X visited, a note in Ms Y’s records shows this was also discussed with her.
42. Regulation 17 2.c states organisations must “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and decisions taken in relation to the care and treatment provided.” Ms Y’s records show staff had concern over several days of loose stool, lack of understanding for simple instructions and recorded food and fluid intake, and where possible output. The records also show what staff discussed with Ms Y’s doctor, and how they followed this advice.
43. As part of my investigation, I asked the Council how staff at the Care Home were trained, and if this included advice on how to recognise signs of sepsis and dehydration. The Council explained the Care Home had an accredited training provider in place who gave compulsory training to all staff. I have seen evidence staff received training courses in sepsis, hydration, and nutrition.
44. I understand why, when her mother’s health declined so quickly, Mrs X would question the care she received at the Care Home, but I have not seen any evidence the care Ms Y received was not in line with guidance. Ms Y being unwell is not, on its own, evidence of poor care.

Complaints about Tavyside Health Centre

Prescribing antidepressants

45. Mrs X complains Ms Y’s doctor put her on antidepressants without discussing it with Mrs X first.
46. On 15 April, Care Home staff spoke to Ms Y’s doctor to explain staff felt her awareness had declined and they were worried about her low mood. The notes show the doctor weighed the pros and cons of starting Ms Y on antidepressants, deciding it could be helpful. There is no reference to either the doctor or staff from the Care Home speaking to Mrs X first.
47. I asked the Health Centre why the doctor did not speak Mrs X before it prescribed antidepressants to Ms Y and if they knew Mrs X held LPA for her mother. It explained it was not clear from looking at their system that Ms Y lacked capacity, but an Alzheimer’s disease diagnosis is listed from 2020. The GP was not aware of Ms Y’s baseline cognition and mood and took the information from the staff reporting at the Care Home. The doctor carried out the consultation with the relevant carer at the Care Home, rather than with Ms Y or Mrs X.
48. The Health Centre accepts Ms Y’s records should have been clearer about both her lack of capacity and the need to consult Mrs X about any decisions about her care. This is fault.
49. Mrs X was distressed when she found out her mother was taking antidepressants without her knowledge. She explains she has not been able to fulfil her legal and moral duties as LPA because of the lack of communication. This is injustice to her caused by the identified fault.

Doctor did not visit Ms Y

50. Mrs X also complains her mother’s doctor did not visit her in the Care Home when she phoned to tell them she was worried about her rapid health decline.
51. On 19 April, Mrs X called the doctor as she worried about her mother and wanted her doctor to visit. She said Ms Y was drowsy and would call back the next day to discuss her concerns. The doctor spoke to the Care Home the same day who said Ms Y was struggling to stand and needed three carers to help her and did not understand even simple instructions. The doctor asked the home to watch her condition and call back if she worsened.
52. On 20 April Mrs X called the doctor again and said Ms Y’s awareness was worse, she was not mobile, and she seemed drowsy. Mrs X explained she was told this was likely to be a progression of Ms Y’s dementia. The doctors’ notes show they “explained common for increase frailty, worse cognition, reduced mobility to occur in patients with dementia after long hospital stay/discharge to a new environment. I would say given these changes this deterioration could be explained by that.” Mrs X said she understood this but wanted the doctor to visit to rule out other causes due to the quick progression of her decline. The doctor did not visit but did ask for a full review of her blood and a CT scan to rule out any other cause.
53. On 22 April the doctor visited Ms Y at the Care Home. Ms Y was “bright and smiling, alert – definitely slightly less talkative than when I last saw at home but no significant deterioration”. The doctor adds “infective cause given bloods, no clear source on exam”. The doctor said they needed a urine sample and Care Home staff said they would try to get one quickly.
54. The doctor called Mrs X to discuss how to manage Ms Y’s condition. The notes state “called daughter [Mrs X] to discuss plan – explained I feel deterioration is infectious – but explained uncertainty about cause”. The doctor and Mrs X then discussed whether Ms Y should go into hospital, both agreed to continue to watch her at the Care Home with a general antibiotic until the cause of infection was found. The doctor advised Mrs X they would call the Care Home on 26 April to review Ms Y’s condition. Ms Y got worse the next day and after discussion, the doctor recommended she go to hospital and staff from the Care Home called an ambulance.
55. Mrs X was distressed when she phoned and spoke to Ms Y’s doctor. She expected the doctor to visit Ms Y to assess her. The doctor spoke to care workers at the Care Home and ordered tests for Ms Y. The doctor decided not to visit Ms Y based on their clinical judgement of the situation. When the test results came and there was increased cause for concern, the doctor visited Ms Y.
56. The General Medical Council’s Good Medical Practice guidance for doctors says they must “promptly provide or arrange suitable advice, investigations or treatment” and doctors should note “the decisions made and agreed actions” in a clear, accurate and legible records.
57. I find no fault with the actions of the doctor, which were in line with guidance. The doctor recorded what action they took, sought investigations, and provided advice to the Care Home to watch her and call back if Ms Y got worse. The doctor also noted they would follow up the next week. The doctor visited Ms Y when the test results showed she had an infection. The doctor then updated Mrs X.
58. While I understand it was distressing to Mrs X the doctor did not visit Ms Y immediately after she told them of her concerns, the doctor did help Ms Y and visited when it became clear she was unwell with an infection rather than a decline of Alzheimer’s disease. Even if the doctor had visited when Mrs X first asked, it would have led to the same plan to arrange tests for her. There is no evidence of fault with the actions of the doctor.

Agreed actions

59. The Ombudsmen recommended and the Health Centre agreed to the following actions.
60. Within one month of the date of the final decision, the Health Centre should write to Mrs X and apologise for the distress it caused by not speaking to her before the doctor prescribed antidepressants to Ms Y. It should send a copy of this letter to the Ombudsmen.
61. Within two months of the date of the final decision, the Health Centre should send a briefing note to all staff reminding them of the importance to check if a patient has a lasting power of attorney for health and welfare, where there is call to suspect a patient may lack capacity, and to consult them before decisions about a patient’s continuing care are reached. It should send a copy of this to the Ombudsmen.

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Final decision

62. I partly uphold Mrs X’s complaint. I found fault by the Trust and Health Centre which led to an avoidable injustice to Mrs X. The agreed actions will provide a suitable remedy. I found no fault by the Council.

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Investigator's decision on behalf of the Ombudsman