Summary: Mr X complained about the treatment and care provided to his late mother, Mrs Y, by the Trust, Council and Practice, after Mrs Y was diagnosed with pneumonia. We found no fault by the Trust in its decision to discharge Mrs Y, although we found fault in its lack of communication with Mr X about this. The Trust provided an appropriate apology to Mr X and has taken reasonable steps to prevent recurrence. We found fault by the Council, in that the care home did not follow up a call to the Practice. We found the care home appropriately apologised and took reasonable steps to improve services. Regarding the complaint about the Practice, we found the Practice took appropriate action to prevent recurrence of the fault it had already identified, in not making a follow up call for a telephone consultation, and has apologised to Mr X.

The complaint

1. Mr X complains about the care and treatment provided to his late mother, Mrs Y, after she was diagnosed with pneumonia. Specifically, he complains that East Lancashire Hospitals NHS Trust (the Trust) should not have discharged Mrs Y from hospital. Mr X also complains the Trust gave Mrs Y medication that she was unable to swallow.
2. Mr X complains that the care home that Mrs Y was discharged to (funded by Blackburn with Darwen Council (the Council)), did not administer her medication properly, and did not seek medical attention for her when she deteriorated.
3. Mr X also complains that Little Harwood Health Centre (the Practice) did not provide Mrs Y with the care she needed, by not following up with a telephone appointment.
4. Mr X questions whether Mrs Y’s death could have been avoided. Mr X also said there was an impact on him of distress and uncertainty about what Mrs Y’s treatment and care should have involved, and whether her care should have been different.
5. In bringing his complaint to the Ombudsmen, Mr X seeks explanations, apologies, and financial remedy.

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The Ombudsmen’s role and powers

6. 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).
7. The Local Government and Social Care Ombudsman investigates complaints about adult social care providers. (Local Government Act 1974, sections 34B, and 34C, as amended). The Health Service Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’ in the delivery of health services (Health Service Commissioners Act 1993, section 3(1)).
8. 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).
9. 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 takes action to stop the same mistakes happening again.
10. 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

11. I considered information from Mr X, the Council, the Trust and the Practice. I also took independent clinical advice from a consultant physician. I also considered the relevant guidance and legislation.
12. Mr X, the Council, the Trust and the Practice 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

Relevant legislation and guidance

13. The following guidance from the National Institute for Health and Care Excellence (NICE) is relevant to the clinical issues raised as part of Mr X’s complaint:

• NICE Clinical Guideline 191, Pneumonia in adults: diagnosis and management;
• NICE Clinical Guideline 138, Pneumonia (community-acquired): antimicrobial prescribing; and
• NICE Clinical Guideline 32, Nutrition support for adults.

14. The Department of Health Hospital Discharge and Community Support Guidance (April 2022) is also relevant to Mr X’s complaint. 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.

What happened

15. Mrs Y had a diagnosis of dementia. She lived in a residential care home, where her placement was funded by the Council.
16. Mrs Y developed symptoms of an infection, and she attended the Trust’s Emergency Department (ED). The Trust treated Mrs Y with intravenous antibiotics in the Acute Medical Unit (AMU), and she also had an X-ray and blood tests. The Trust diagnosed Mrs Y with pneumonia. After two days in hospital, Mrs Y was admitted to a ward. The next day, 21 November, Mrs Y was discharged back to the care home with antibiotics.
17. On 24 November, the care home contacted the Practice about Mrs Y’s symptoms. However, a discussion between the care home and the Practice did not take place. On 26 November, the care home called 111, and Mrs Y returned to hospital that day. Sadly, Mrs Y later died in hospital.

Analysis

18. As Mr X has complained about the Trust, the Council (in relation to the care provided at the care home), and the Practice, I have set each of these out under separate headings, below.

The Trust – discharge from hospital

19. Mr X complained Mrs Y should not have been discharged as this was just hours after she had been diagnosed with pneumonia, and was readmitted soon after leaving hospital. Mr X said Mrs Y was not well enough to have left hospital at that time, and said the Trust should have continued treating her for pneumonia in hospital.
20. As noted above, the Trust diagnosed Mrs Y with community-acquired pneumonia. This was based on clinical findings, chest X-ray and blood test results. The Trust treated Mrs Y’s pneumonia in line with the NICE guideline 191, Pneumonia in adults: diagnosis and management, referred to above.
21. The Trust records also refer to a system known as CURB65. This is used alongside clinical judgment to assess how severe someone’s illness is, and whether hospital treatment is needed or if the person can be treated at home. Home-based care is considered for scores 0-2. The Trust recorded Mrs Y’s illness as level 2, which is the threshold for considering hospital care, which she received.
22. The Trust also gave Mrs Y intravenous antibiotics, which is in line with NICE guideline 138, Pneumonia (community-acquired): antimicrobial prescribing. Guideline 138 says intravenous antibiotics should be reviewed after 48 hours and switching to oral antibiotics should be considered. Mrs Y received just over 48 hours of intravenous antibiotics, followed by oral treatment, which was in line with the guidance.
23. Regarding the decision to discharge Mrs Y, this was in line with the Department of Health Hospital Discharge and Community Support Guidance “criteria to reside” in hospital. It was also in line with NICE guideline 191, on safe discharge from hospital.
24. This provides the following guidance on safe discharge from hospital (section 1.2.19):
25. “Do not routinely discharge people with community-acquired pneumonia if in the past 24 hours they have had 2 or more of the following findings:

• temperature higher than 37.5°C
• respiratory rate 24 breaths per minute or more
• heart rate over 100 beats per minute
• systolic blood pressure 90 mmHg or less
• oxygen saturation under 90% on room air
• abnormal mental status
• inability to eat without assistance.
• Consider delaying discharge for people with community-acquired pneumonia if their temperature is higher than 37.5°C.”

26. The clinical assessment on the morning Mrs Y was discharged, together with a physiotherapy assessment and reference to the guidance above, indicate the Trust’s decision to discharge Mrs Y back to the care home, with continuing oral treatment for pneumonia, was in line with the relevant guidance.
27. In responding to Mr X’s complaint, the Trust explained its reasons for discharging Mrs Y. It said after being treated for pneumonia with antibiotics, Mrs Y’s observations were stable, and her blood tests showed improvement. The Trust said this information indicated Mrs Y’s clinical condition had improved and that she was responding to the antibiotics.
28. The Trust also said Mrs Y was reviewed by therapists, who said she did not need any additional support and the level of care provided in hospital could be provided at the care home. The Trust said therefore it considered it was an appropriate decision to discharge Mrs Y.
29. The Trust’s response is supported by the information in the records, and it has given a reasonable explanation for its decision to discharge Mrs Y. The records available indicate the Trust considered the decision carefully and that it was in line with available guidance. Therefore, I have not found fault by the Trust in its decision to discharge Mrs Y.
30. Part of Mr X’s complaint about the Trust’s decision to discharge Mrs Y, was that the Trust failed to communicate with Mrs Y’s family about this. Mr X said this meant the family did not get information they needed about what would happen if Mrs Y’s symptoms became worse, and whether she would then be looked after at the care home or come back to hospital. Mr X also said Mrs Y’s dementia meant she was unable to discuss the discharge decision herself.
31. The Hospital Discharge guidance referred to in paragraph 20, says NHS organisations should ensure that, where appropriate, family members are involved in discharge decisions.
32. In not discussing discharge planning with Mrs Y’s family, the Trust did not act in line with the national discharge guidance. This was fault by the Trust.
33. In its response to Mr X’s complaint, the Trust acknowledged discussions with Mr X, about what would happen if Mrs Y’s symptoms became worse, did not take place. The Trust apologised to Mr X for the lack of communication, and acknowledged this could have given him the opportunity to raise any concerns at the time.
34. I recognise the lack of communication about discharge planning caused Mr X distress and uncertainty about whether Mrs Y’s care could have been different. However, I am unable to say whether, if the Trust had discussed discharge planning with Mr X, this would have changed the plan for Mrs Y’s care. As noted above, I found no fault by the Trust in its decision to discharge Mrs Y at that time.
35. The Trust acknowledged the lack of discussion meant Mr X missed an opportunity to raise any concerns, and it appropriately apologised to Mr X for the lack of communication. The Trust also said the team would learn from Mr X’s complaint by reflecting on how to improve discussions with patients and families in future. The Trust has taken reasonable steps to improve services following Mr X’s complaint.

The Trust - antibiotics

36. Mr X also complained the antibiotics the Trust prescribed were not suitable for Mrs Y as she could not swallow them. Mr X said Mrs Y had a history of poor swallowing reflex because of her dementia diagnosis. He said that another family member and Mrs Y’s care worker said she was having trouble swallowing the tablets after leaving hospital.
37. In its response to Mr X’s complaint, the Trust said it had assessed Mrs Y when she was admitted to hospital, and had not diagnosed any problems with swallowing. It said there was nothing in the nursing notes to indicate Mrs Y had any problems taking the medication.
38. The Trust’s response reflects the information from Mrs Y’s medical and nursing records, which give no indication she had any difficulty swallowing while she was in hospital. During Mrs Y’s admission, the Trust completed food and drinks charts for Mrs Y, showing meals and drinks taken. Being able to swallow food and drinks would be an adequate indication that oral antibiotics could be given.
39. Completed medication charts also show Mrs Y took oral medication while in hospital. The decision to use oral antibiotics was in line with the NICE guidance on treating pneumonia, as set out in paragraph 20.
40. There was no indication in the records that Mrs Y was unable to swallow, nor that she needed a more detailed swallowing assessment. NICE guideline 32, Nutrition support for adults, describes the signs that a person may have problems with swallowing that mean they should be referred to a healthcare professional with training in swallow disorders. However, none of these indicators were present for Mrs Y. Therefore, there was no reason for the Trust to request a swallow assessment.

• I recognise Mr X’s view that Mrs Y had a history of swallowing difficulties. However, in line with the above guidance, being able to swallow food and drink would be an adequate indication to receive oral antibiotics. Therefore, I have not found fault by the Trust in its decision to give Mrs Y oral antibiotics.

The Council – care provided at the care home

41. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended).
42. Mr X complained the care provider, acting on behalf of the Council, did not take Mrs Y’s symptoms seriously and did not escalate matters when her condition deteriorated. Mr X said Mrs Y was vomiting bile and the care home should have referred to managers to decide what to do. He said handover between care staff did not provide relevant information. Mr X also complained the care home did not give Mrs Y her medication as it should have done.
43. In its response to Mr X’s complaint, the care home said Mrs Y took antibiotics as prescribed between 22 November and 26 November, except for one occasion when she could not take the tablets (the night of 25 November). The response says difficulty taking tablets was not due to problems with swallowing but because of vomiting. The records show three occasions when Mrs Y vomited, on 23, 24 and the night of 25 November.
44. On 24 November, care home staff contacted the Practice about Mrs Y vomiting. They left a message detailing the issue and requested a call back. The records for the end of the day say there had not yet been a call back from the Practice. There is a difference in the accounts of the care home and the Practice, as the Practice records say it called back but there was no answer from the care home. I will come to this later in this decision statement. However, both the care home and the Practice acknowledged there was no follow-up discussion of Mrs Y’s care that day.
45. As noted above, the care home records show Mrs Y vomited again during the night on 25 November and was unable to take her antibiotics that evening. However, I have not seen anything in the records for 25 November to indicate the care home was waiting for a call back, or that the care home followed up with the Practice that day. On 26 November, the care home carried out observations for Mrs Y and called 111. Mrs Y was readmitted to hospital that day.
46. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
47. Regulation 17 is about good governance. This says providers must keep accurate, complete and contemporaneous records for people receiving care. This includes records of care provided, and of decisions about care and treatment. The guidance states this means records must be accurate and up to date.
48. As noted above, there was a lack of information in the handover notes for 25 November, as there was no indication that advice had been sought from the Practice, but the call had not yet taken place. This was not in line with the Regulations set out above and therefore I found fault by the Council on this point.
49. In responding to Mr X’s complaint, the care home acknowledged this gap in the handover information. It also apologised to Mr X for not following up the telephone call to the Practice. The care home said to prevent a similar situation happening again it had taken steps to improve communication between staff, by reminding staff of the importance of ensuring handovers are clear and contain the relevant information. The care home also said it had shared learning with its senior teams to ensure handovers were properly documented, “to include any professional contact awaiting, this allows the team to recognise if a follow-up hasn’t been received.”
50. The care home said it had also purchased mobile phones for each floor of the care home so it can be contacted out of hours. It said senior care staff carry the mobile phones with them while on the floor.
51. I recognise this caused distress and uncertainty to Mr X, regarding whether Mrs Y’s care may have been different, had the care home made a follow-up call to the Practice. The care home (on behalf of the Council) has provided an appropriate apology to Mr X for distress. The care home has also taken reasonable steps to improve its service in future.

Complaint about the Practice

52. Mr Y complained the Practice failed to follow up a telephone appointment with the care home. He said therefore there was no discussion between the Practice and care home about Mrs Y.
53. Mr X complained to NHS England (NHSE) about the Practice. The Practice investigated his complaint and found it had booked a telephone consultation and had advised the care home it would be that afternoon. The Practice provided an extract from its records showing it made a call to the care home that afternoon, but said “there was no answer and no answerphone service”. The Practice acknowledged it had then not followed its usual process for returning calls to patients. It said its best practice protocol states it will call patients on their preferred number, a minimum of two times, leaving a message where possible. However, it said it was unable to identify that a second call had been made.
54. NHSE also carried out a clinical review of the complaint, and made recommendations to the Practice to improve its services as a result of Mr X’s complaint. This included reviewing its protocol for managing telephone consultations, and monitoring adherence to the protocol.
55. The Practice carried out an appropriate investigation into Mr X’s complaint and considered relevant records, which were reflected in its response to Mr X. As noted above, the Practice’s response to Mr X acknowledged it had not followed the process for telephone consultations. I recognise Mr X’s view that this caused him uncertainty and distress. The Practice appropriately apologised to Mr X for upset and distress caused.
56. I have considered the actions the Practice has taken following Mr X’s complaint. I consider the actions taken, including a review of its telephone consultation protocol and how it will monitor adherence to this, are reasonable and will help prevent recurrence. Therefore, I have not made any further recommendations for service improvement by the Practice.

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Final decision

57. I found fault by the Council, the Trust and the Practice, for the reasons set out in the Analysis section, above. The Council, the Trust and the Practice have offered reasonable remedies by apologising to Mr X for the uncertainty caused to him, and taking appropriate actions to improve services. I have completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman