Privacy settings

LGO logogram

Review your privacy settings

Required cookies

These cookies enable the website to function properly. You can only disable these by changing your browser preferences, but this will affect how the website performs.

View required cookies

Analytical cookies

Google Analytics cookies help us improve the performance of the website by understanding how visitors use the site.
We recommend you set these 'ON'.

View analytical cookies

In using Google Analytics, we do not collect or store personal information that could identify you (for example your name or address). We do not allow Google to use or share our analytics data. Google has developed a tool to help you opt out of Google Analytics cookies.

Medway NHS Foundation Trust (16 015 734a)

Category : Health > Hospital acute services

Decision : Upheld

Decision date : 07 Mar 2019

The Ombudsman's final decision:

Summary: Miss D complains about care and treatment of her father, Mr D, by two NHS Trusts while he was in hospital. She also complains about the way the Council assessed and provided for Mr D’s social care needs. The Ombudsmen have upheld parts of Miss D’s complaints and made recommendations for service improvements. The Council and NHS Trusts agree to the recommendations, so the Ombudsmen have completed their investigation.

The complaint

  1. The complainant, whom I shall call Miss D, complains about the actions of the Council and two NHS Trusts in relation to her father, Mr D. Specifically, she complains that
    • there were flaws in Mr D’s care and treatment by Medway NHS Foundation Trust’s Accident and Emergency (A&E) department and two of its hospital wards,
    • there were flaws in Medway NHS Foundation Trust’s communication with
      Miss D during those periods of treatment,
    • there was no clear diagnosis of the causes of Mr D’s cognitive issues/brain lesions or an explanation of the reasons for these,
    • the Council and Medway NHS Foundation Trust delayed assessing Mr D’s capacity to decide where he wanted to be discharged to, leading to a delayed hospital discharge,
    • Mr D’s placement at Copper Beeches, a Council-commissioned care home in Rochester run by Four Seasons Health Care, was inappropriate,
    • Mr D received poor care at Copper Beeches care home.

Back to top

The Ombudsmen’s role and powers

  1. 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)
  2. The Ombudsmen cannot investigate late complaints unless they decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to the Ombudsmen about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).)
  3. 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).
  4. 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.
  5. The Ombudsmen may investigate, and question the merits of, action taken in the exercise of clinical judgement.
  6. 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. 
  7. 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)
  8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

Back to top

How I considered this complaint

  1. I have considered information Miss D has provided in writing and by telephone. I have also considered photographs Miss D has provided.
  2. The Council and the two Trusts have had an opportunity to comment on the complaint and provide evidence. I have considered documentary evidence provided by the Council and Trust.
  3. I have sought clinical advice from
    • a consultant in emergency medicine
    • a senior nurse with expertise in the care of older people
    • a consultant physician specialising in elderly care (geriatrician)
    • a consultant urologist
    • a neurologist with experience of stroke, small vessel disease and vascular dementia
    • a psychiatrist specialising in dementias, who works with older adults with dementias and mental health problems.
  4. I have considered the clinical advice as evidence relevant to the investigation.
  5. I have exercised the discretion available to me to investigate complaints about matters Miss D was aware of for more than 12 months before she first complained to the Ombudsmen in July 2016. These are, in summary, the A&E attendance in October 2014 and the period in hospital between March and June 2015. I have decided to do this because I considered that
    • what happened during the A&E attendance of October 2014 may have had a bearing on the hospital admission in 2015,
    • Miss D was not aware of the full extent of the problems with care, treatment and discharge from hospital until October 2015, less than 12 months before she first complained to us. To investigate those matters fairly, we would need to look at the entire period between March and October 2015,
    • Miss D complained to Medway Trust soon after the matters she complains about happened, but did not receive a response until November 2016.
  6. The complainant, Council and two Trusts have had an opportunity to comment on a draft version of this decision.

Back to top

What I found

  1. The Mental Capacity Act 2005 (MCA) is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The MCA (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person's capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so themselves.
  2. Key elements of the MCA and Code relating to this complaint are that
    • there is a presumption that individuals have capacity unless there is proof to the contrary
    • someone can have capacity and still make unwise decisions
    • where a council or NHS body suspect that a person lacks capacity to make a decision, they must assess the person’s capacity to make that decision.
  3. An assessment of someone’s capacity is specific to the decision to be made at a particular time. When assessing somebody’s capacity, the assessor needs to find out:
    • Does the person have a general understanding of what decision they need to make and why they need to make it?
    • Does the person have a general understanding of the likely effects of making, or not making, this decision?
    • Is the person able to understand, retain, use, and weigh up the information relevant to this decision?
    • Can the person communicate their decision?
  4. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity must be done, or made, in that person’s best interests. Section 4 of the Act provides a checklist of steps that decision-makers must follow to decide what is in a person’s best interests. The decision-maker must also consider if there is a less restrictive option available that can achieve the same outcome.

Falls in hospital

  1. The National Patient Safety Agency produced the Slips, trips and falls in hospital Report in February 2007. This aimed to improve understanding of the scale and impact of slips, trips and falls within the NHS, and to encourage staff at all levels to renew efforts to prevent these. It noted there would always be risk of falls in hospital. It provided suggestions of what could be done to reduce the risk of falls while properly allowing patients freedom and the ability to mobilise during their admission.
  2. In June 2013, National Institute for Health and Care Excellence (NICE) issued the clinical guideline “Falls in older people: assessing risk and prevention (CG161)”. This notes that all patients over the age of 65 should be treated as at high risk of falling in hospital. The guidance says that staff should identify and address individual risk factors that can be treated or improved. Some risk factors cannot be changed, for example the fact that a person has dementia. The NICE guideline “Head injury: assessment and early management CG176” says that where an adult aged 65 or over experiences a loss of consciousness or amnesia after a head injury, a computerised tomography (CT) head scan should be done within eight hours of the injury. A CT scan uses X-rays and a computer to create detailed images of the inside of the body.

Record keeping – nursing

  1. The Nursing and Midwifery (NMC) issued The Code in 2009. This sets out standards of conduct, performance and ethics for nurses and midwives. It says clear and accurate records should be kept of discussions, assessments, treatment and medicines given, along with how effective these have been.

Hygiene in hospital and residential care

  1. The Department of Health has issued codes of practice for health and adult social care on the prevention and control of infections. The guidance relevant to the time of the complaint was issued in December 2010 and updated in July 2015. Criterion 2 relates to providing and maintaining a clean and appropriate environment. Guidance for complying with this says that providers should normally ensure that
    • premises are kept clean
    • the cleaning arrangements detail the standards of cleanliness
    • a schedule of cleaning frequency is available on request
    • the supply and provision of linen and laundry are suitable for the level and type of care.

Social care assessments and plans

  1. The Care Act 2014 requires local authorities to carry out an assessment for any adult with an appearance of need for care and support. The assessment must determine whether the adult has social care needs and how these can be met.
  2. The statutory guidance that accompanies the Care Act 2014 says a council must carry out the assessment over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs. Local authorities involve the individual and, where appropriate, their carer or any other person they wish to be involved.
  3. The local authority should record the person’s needs, and how these will be met, in a care and support plan (or a support plan for a carer).

Discharge from hospital

  1. Department of Health guidance: Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate care (March 2010) (the ‘Ready to go guidance’) is the core guidance around 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.
  2. Department of Health guidance: Definitions – Medical Stability and ‘Safe to Transfer’ (2003) (the ‘Safe to transfer guidance’) gives guidance on when a patient can be safely considered to be ‘medically fit for discharge’. This lists three key criteria for this decision and stresses professionals should address them at the same time, if possible. According to the protocol, a person is considered to be safe for discharge when:
    • there is a clinical decision that the patient is ready for transfer;
    • there is a multidisciplinary team decision that the patient is ready for transfer; and
    • the patient is safe to discharge/transfer.
  3. A patient can be defined as clinically or medically stable if tests (such as blood tests and observations) are 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 need a multidisciplinary assessment.
  4. Schedule 3 to the Care Act 2014 and the Care and Support (Discharge of Hospital Patients) Regulations 2014 make provisions on the discharge of hospital patients with care and support needs.
  5. The NHS must issue a notice to the local authority where it considers an NHS hospital patient receiving acute care may need care and support as part of a transfer from an acute setting. The NHS should try to give the local authority as much notice as possible of a patient’s impending discharge.
  6. On receiving an assessment notice, the local authority must assess the person’s care and support needs and (where applicable) those of a carer to decide whether it considers the patient and carer have needs. The local authority must then decide whether any of these identified needs meet the eligibility criteria. If so, it should confirm how it proposes to meet any of those needs. The local authority must tell the NHS of the outcome of its assessment and decisions.

Quality of residential care

  1. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets out the requirements for safety and quality in residential care provision from 1 April 2015.
  2. Regulation 9 addresses person-centred care. It says care must be appropriate, meet the person’s needs and reflect their preferences. This includes having regard to the person’s well-being when meeting their needs for food and drink.
  3. Regulation 10 says people must be treated with dignity and respect. This includes ensuring their privacy and supporting their autonomy and involvement in the community.
  4. Regulation 14 addresses meeting needs for food and drink. It requires that people
    • get a choice of suitable and nutritious food and drink which is enough to sustain life and good health
    • are supported to eat and drink if necessary.
  5. Regulation 15 addresses premises and equipment and says that
    • the care provider’s premises and equipment must be clean and suitable for the purpose for which they are used
    • the care provider must maintain appropriate standards of hygiene.

What happened

  1. Mr D was admitted to Medway Trust’s A&E department in October 2014 after being found driving erratically despite not drinking. After he was seen by A&E medics, he discharged himself and went home in a taxi.
  2. Mr D fell at home and was admitted to the Medway Trust’s hospital on 27 March 2015. During his admission, Mr D was also seen by a liaison psychiatry service provided by Kent & Medway NHS & Social Care Partnership Trust (Kent Trust).
  3. The Council started a ‘Long Term Assessment’ on 25 May 2015 and completed it on 21 June 2015. This decided he should have a package of care in his own home, supported by Miss D. The Council updated this assessment on 2 July 2015 because Miss D was no longer able to support Mr D at home. This said the discharge plan was now for a temporary nursing placement subject to review.
  4. The Council did another ‘Long Term Assessment’ between 12 and 23 September 2015. This recommended a residential home with nursing.
  5. After just over six months in hospital, Mr D was discharged to Copper Beeches care home, a residential care home placement arranged by the Council, on 12 October 2015.
  6. Mr D moved back to his own home on 9 December 2015.

A&E admission October 2014

  1. Miss D complains Medway Trust
    • discharged her father from A&E despite the condition he was in
    • did not inform Mr D’s family
    • did not offer a follow up or provide treatment for vascular issues highlighted by scans taken by A&E
    • did not investigate whether there was a link between Mr D’s cancer and mobility problems.
  2. Medway Trust’s A&E records for this admission show that
    • Mr D refused to let staff contact his wife or daughter,
    • staff recommended Mr D stay, but he refused and had capacity to make that decision and signed a “Discharge Against Medical Advice” form.
  3. The clinical adviser commented that
    • there is evidence of multiple assessments of Mr D’s capacity and abilities by multiple staff and that those assessments were appropriate
    • there was an appropriate clinical assessment that checked for any obvious acute medical problems which did not show anything new of obvious concern
    • Mr D made a capacitated decision to refuse the request that he stay in hospital for more tests
    • as a result A&E staff did not get a chance to offer follow up investigation or outpatient.
  4. I have considered the clinical advice as evidence relevant to my investigation of this complaint.
  5. There was no fault in the Trust discharging Mr D and not informing his family of his A&E admission and discharge.
  6. Medway Trust has no record of A&E communicating with Mr D’s GP. This is a fault because the NHS Standard Contract for 2014/15 requires A&E providers to issue a discharge summary to a patient’s GP. We do not know whether a discharge summary was sent but no record made, or if the lack of record confirms that no discharge summary was sent.
  7. I consider that this has not caused Mr D a significant injustice. This is because his medical records indicate that his GP and community mental health team were aware of the concerns about Mr D’s health and behaviour around this time.

Care and treatment on hospital wards March – September 2015

  1. Miss D says
    • the hygiene on the wards was poor
    • Mr D was given food before he was due to have anaesthetic
    • the Medway Trust did not monitor the spread of Mr D’s prostate cancer or treat it while Mr D was in hospital until she intervened
    • the monitoring was inadequate even after her intervention
    • staff gave Mr D an overdose of hormone treatment
    • the Medway Trust did not perform a CT scan as it said it would, after Mr D fell on the ward and cut his eye
    • the Medway Trust delayed referring Mr D to an eye clinic for four months
    • the Medway Trust delayed dealing with Mr D’s eye problems in September 2015 and misdiagnosed the problem as conjunctivitis, leading to discomfort over several days
    • there were problems with the way staff in the urology department dealt with
      Mr and Miss D at two appointments in August 2015.

Hygiene on the hospital wards

  1. Medway Trust has no contemporaneous records of cleaning Mr D’s ward or of cleaning schedules for the time Mr D was in hospital. Given the time that has passed, I do not consider it fault that the Trust has not kept these. Medway Trust has been able to show us infection control and disinfection policies that applied during Mr D’s stay in hospital. However, these do not cover the general cleaning and housekeeping that Miss D is concerned about.
  2. Some of the photographs Miss D has provided are unclear. Others show dirt and spillages on floors and an unmade hospital bed. While the photographs show the situation at the time they were taken, they do not show context, such as
    • how often the problems happened or how long they lasted,
    • when the spillages were cleaned, for example soon after they happened or hours or days later.
  3. The photographs do show that at times Mr D’s environment was not clean. However, there is not enough evidence that this was because of Medway Trust acting with fault and not complying with Government guidance. Further investigation is unlikely to find more evidence of fault.

Prostate cancer treatment (including MRI delay, hormone treatment overdose and urology staff attitude)

  1. Mr D’s clinical notes show Medway Trust staff were aware of a history of prostate cancer on admission to hospital.
  2. Three days after Mr D went into hospital, Miss D discussed her concerns about Mr D’s prostate cancer with hospital staff. Staff requested a blood test to help detect prostate cancer on the same day. Test results showed a raised level of prostate-specific antigen (PSA) in Mr D’s blood. Mr D had a bone scan on 17 April which showed ‘multiple bone metastases’ which means cancer that has spread to the bone. Mr D was reviewed by a urologist on 21 and 23 April.
  3. After Mr D forcefully rejected an injection of Zoladex (hormone used to treat symptoms of prostate cancer), liaison psychiatry assessed his capacity to decide whether to be treated for prostate cancer on 28 April. They decided Mr D lacked capacity to make this decision and that it would be in his best interest to get treatment. As a result, the team caring for Mr D decided to sedate Mr D before carrying out a Magnetic Resonance Imaging (MRI) scan booked for 30 April. MRI is a type of scan that uses strong magnetic fields and radio waves to make detailed images of the inside of the body. Although Mr D’s clinical notes say he should have fasted before sedation, he ate in the morning, so the MRI scan was postponed until the next day. Overnight, Mr D drank water from a tap and his clinical notes say he may have eaten food from a table so the MRI scan was postponed again, until the afternoon of 1 May.
  4. Orthopaedic doctors reviewed Mr D’s MRI results and saw Mr D on 11 and 12 May. They concluded that no further input from orthopaedics was required.
  5. Although the MRI was delayed twice because Mr D ate and drank, the available evidence does not indicate this was because of fault by the Trust. The clinical notes indicate that at the time Mr D was mobile and unwilling to comply with staff requests not to eat and drink.
  6. The clinical advisers specialising in urology and elderly care have commented that the result of the scan did not show any disease that needed different treatment, so an earlier scan would not have led to any other treatment.
  7. Taking all the available evidence into account, I consider that the MRI delay was not significant or the result of fault by the Medway Trust and did not cause Mr D harm.
  8. Clinical notes show urology specialists saw Mr D on his hospital ward at least three times.
  9. Mr D also had an appointment at the hospital’s urology clinic on 4 August 2015. Mr D’s clinical notes for that appointment say
    • Mr D arrived for the appointment late and without an up to date blood test having been done
    • Miss D accompanied Mr D to the appointment
    • the member of staff who saw them explained they needed the results of the blood test to find out the effectiveness of the Zoladex treatment and said they would arrange for a blood test and further appointment in the next couple of weeks
    • the staff member also explained they could not assess Mr D’s prostate cancer history because they only had part of his notes and they asked a colleague to bring the rest of the notes from Mr D’s ward
    • Miss D was unhappy about this, swore at the staff member and threw her bag at their feet
    • the staff member left the clinic room and spoke to a consultant who advised they try to complete the review with another colleague present
    • the staff member followed this advice, explained what the hospital had done so far to monitor and treat Mr D’s prostate cancer and explained again they could not review the effectiveness of the treatment until they had up to date blood test results.
  10. This incident was clearly frustrating and inconvenient for all involved. However, there is no indication Mr D suffered harm as a result. The Medway Trust has provided an appropriate apology for its part in what happened.
  11. Mr D should have had a Zoladex injection at a dose of 10.8 mg once every three months. He received the injections in April, May and October 2015. Clinical notes say
    • the injection Mr D received in April was not documented in his notes at the time he received the second dose in May,
    • because of this, a nurse administered another injection in May, believing Mr D had not had the previous injection.
  12. These were faults by the Medway Trust.
  13. Clinical notes also show that
    • when hospital staff became aware of the overdose in early June 2015, they consulted the urologist and Toxbase (a clinical toxicology database), discussed the problem with Miss D, apologised and ordered blood tests for Mr D
    • they were advised that a Zoladex overdose had no overwhelming side effects and the next dose should be given in August
    • doctors explained what had happened and apologised to Miss D.
  14. The Medway Trust also recorded this on its incident reporting system and took action to remind doctors of their responsibilities for recording administered medications. The Medway Trust also referred the matter to its Medicines Management Committee.
  15. The clinical advisers specialising in geriatrics and urology reviewed Mr D’s clinical records and commented that
    • Zoladex overdose has no overwhelming side effects and does not cause harm to the patient
    • clinical records showed Mr D had no apparent symptoms, so it would seem he did not suffer harm from the overdose
    • the Medway Trust took the correct action when it became aware of the overdose by checking whether it would cause harm, reporting it, learning lessons from it and apologising.
  16. The clinical adviser (geriatrics) has commented that the medical team responsible for the overall management of Mr D’s care in hospital (geriatrics) liaised appropriately with the experts in prostate cancer treatment (urology). The clinical adviser (urology) has commented that
    • the hospital did the relevant investigations as recommended by NICE for patients with prostate cancer
    • the hospital correctly prescribed hormone injection treatment
    • they could see no flaws in the care provided to Mr D.
  17. Taking all the available evidence into account, I consider that
    • the Medway Trust’s overall management of Mr D’s prostate cancer was reasonable,
    • the flaws that I have identified, including the Zoladex overdose, did not cause Mr D significant problems,
    • the Medway Trust has taken appropriate action in response to the overdose.


  1. Miss D says the Medway Trust failed to carry out a CT scan after Mr D fell and cut his eye.
  2. The Medway Trust’s “Slips, Trips and Falls policy” applicable at the time of Mr D’s admission includes the following
    • a Datix (incident reporting software) incident should be completed “where there has been a slip, trip or fall occurring on Trust premises”,
    • a falls risk assessment will be done within 12 hours of admission,
    • there should be risk assessments of the surroundings of patients who may be vulnerable due to age or reduced mental capacity; these should be updated following changes in circumstances,
    • where there are risks, there will be a “Falls individualised care plan”, assessment of equipment and consideration of bed rails, low bed or fall alarms
    • there should be strategies to prevent further falls,
    • when a patient falls, a nurse and doctor must assess them and complete a post fall checklist,
    • “A CT Scan of the patient’s head should be considered urgently in any patient who shows neurological change or decline following a fall”
    • the patient’s falls assessment and care plan should be reviewed weekly or following a fall.
  3. The Medway Trust has provided Datix records, clinical notes and ‘Post Fall Checklists’ recording Mr D’s falls between April and October 2015. The Datix records, clinical notes and post fall checklists do not always match each other.
  4. The post fall checklist for 11 August 2015 relates to the fall Miss D complains about in particular, where Mr D received a cut above his eye as he fell. The doctor’s assessment for that fall does not say that Mr D should have a CT scan. It says, “if GCS [Glasgow Coma Scale, a way of recording the conscious state of a patient] drops, will need CT brain”. This corresponds with the Medway Trust’s policy and NICE guidelines.
  5. The geriatrician clinical adviser has commented that
    • there was no record Mr D lost consciousness as a result, so it was a matter of clinical judgement whether to perform a CT scan
    • Mr D does not appear to have suffered any adverse consequences as a result.
  6. Based on the evidence I have seen, I consider that there was no fault in the decision not to perform a CT scan after the fall of 11 August 2015.
  7. The records show Mr D had a total of eight falls in hospital. But the records do not match because
    • there are no post fall checklists for three of the falls recorded elsewhere
    • there are no Datix records for three of the falls recorded elsewhere
    • there is no record in the clinical notes of one fall recorded elsewhere.
  8. The nursing clinical adviser has commented that
    • preventing patient falls in hospital is a challenge because hospitals have to balance patients’ safety against their right to make their own decisions about the risks they are prepared to take, their dignity and privacy. Rehabilitation always involves risks and a patient who is not permitted to walk without staff may become a patient who is unable to walk without staff;
    • the hospital was aware of Mr D’s risk of falls from the time he was admitted on 26 March 2015;
    • there is evidence of fall care plans that were regularly updated;
    • records show nursing and physiotherapy interventions to address risk of falling, mobility and balance problems;
    • Mr D’s balance and mobility problems were the major risk factor for falling;
    • records say Mr D could be unpredictable when moving, often declined to participate in physiotherapy and declined supervision when getting around;
    • without Mr D complying with rehabilitation and physiotherapy, the risk of falling could not be reduced;
    • after each fall, nursing staff tried to follow the post-falls protocol but Mr D was not always willing to allow observations or examinations. Clinical staff can encourage a patient to accept interventions but cannot force the patient to do so;
    • the evidence indicates there were failings in record keeping;
    • however, the evidence does not indicate that any of Mr D’s falls could have been prevented.
  9. Based on the information available, I consider there is fault in the Medway Trust’s record keeping, which does not comply with guidance or policy because of missing Datix records, post falls checklists and clinical notes of some falls.
  10. However, none of the evidence indicates that Mr D would have fallen less often if there was no fault in the Medway Trust’s record keeping. The evidence also indicates Mr D did not suffer significant harm as a result of the falls.
  11. To prevent similar flaws recurring, which could affect others, the Medway Trust should act to improve as outlined in the recommendations.

Eye problems

  1. Mr D’s clinical records contain notes about eye problems in June, July and September 2015. The records for July 2015 show Miss D told a staff member she had concerns about Mr D’s eyes being sensitive to light. This was during evening visiting hours. The staff member apologised and said Miss D should be able to get an update from the day team. There are no further records of Miss D discussing this with staff.
  2. The clinical adviser has commented that
    • the references in clinical notes to red itchy eye being treated with topical antibiotic on 5 May 2015 and 9 September 2015 indicate this was not an ongoing problem for Mr D,
    • the treatment appears appropriate and as the problem appeared to settle it would not be usual practice to pursue the matter further,
    • had the problem not settled with initial treatment, it would have been good practice to ask for a further opinion from the ophthalmology team.
  3. The available evidence does not indicate fault in the way the Medway Trust managed Mr D’s eye problems.

Trust’s communication with Miss D

  1. Miss D says the Medway Trust communicated with her poorly while Mr D was in hospital, including failing to inform her about Mr D’s falls. She also says the Medway Trust delayed dealing with her complaint.

Communication about falls

  1. Mr D’s clinical notes and multidisciplinary team communication sheet record that staff informed Miss D of Mr D’s fall of 4 October 2015. There are no records of staff informing Miss D of the other seven falls Mr D had.
  2. The evidence I have considered so far indicates it is more likely than not that the Medway Trust failed to tell Miss D about most of Mr D’s falls as soon as possible after they happened. This is because the lack of records of the Medway Trust informing Miss D of falls matches Miss D’s recollection that she was not told about them. Medway Trust should have discussed these with Miss D because she was a close family member involved in Mr D’s care and discharge plans. Not doing so was fault. I have made recommendations below.

Other communication

  1. Mr D’s hospital records indicate staff communicated with Miss D regularly while Mr D was in hospital, either in person or by telephone. The records of communication appear to be written soon after the event but are not a record of every word spoken or the tone of the communication. They do not contain any references that I would consider to be inappropriate or offensive.
  2. The nursing adviser has commented that
    • nursing’s regulatory body has issued guidance to nurses for communication with patients and their families
    • there are many entries in the clinical and nursing notes showing telephone and face-to-face communication with Miss D during her father’s stay in hospital
    • the adviser cannot establish the quality of the communication with Miss D from the entries
    • the documents indicate the frequency of communication was reasonable.
  3. I have addressed communication about diagnosis of cognitive problems separately below.
  4. The available evidence, including the hospital records and Miss D’s description of her concerns about communication, indicates that the remainder of the Trust’s overall communication with Miss D while Mr D was in hospital was sufficient.
  5. Miss D complained to the Medway Trust in October and December 2015 about
    Mr D’s A&E admission and his care and treatment between March and October 2015. The Medway Trust responded to her complaint in November 2016. This was a significant delay. The Medway Trust’s response acknowledged that the time it took to reply was unacceptable and said it was sorry for Miss D’s poor experience. The Medway Trust said that it had put measures in place to improve its administration of complaints. I consider the measures the Medway Trust has already taken are an appropriate way to address the problem.


  1. Miss D complains that there was a lack of clear diagnosis relating to Mr D’s cognitive issues/brain lesions or an explanation of the reasons for these.
  2. The Medway Trust says that
    • it did a CT scan on the day Mr D was admitted to hospital because Mr D had a history of falls
    • the scan showed small vessel cerebrovascular disease
    • cerebrovascular disease is associated with problems of the circulation of the blood to the brain
    • the term ‘multi-infarcts disease’ is sometimes used to refer to this condition
    • people who have it can have cognitive impairment and become unsteady on their feet, which relates to the recurrent falls.
  3. Mr D’s hospital clinical notes record he was seen four times by neurology, and 20 times by the Kent Trust’s liaison psychiatry.
  4. An assessment of Mr D’s capacity to make decisions about medical procedures such as sedation and scans completed by a Medway Trust doctor on 1 May 2015 states “early stage dementia”.
  5. Mr D’s hospital clinical notes record clinicians’ discussions with Mr D’s family on 23 occasions. The clinical notes record the following
    • a discussion between a consultant and Miss D on 6 May 2015 where the consultant records discussing early stage dementia with Miss D,
    • a discussion with Miss D on 11 May 2015 where Miss D asked questions about Mr D’s difficulties. The record indicates a member of hospital staff discussed vascular dementia, muscle weakness and small vessel disease with Miss D. The staff member notes they explained that a brain scan indicated small vessel disease and that Mr D was seen by the psychiatry service,
    • a doctor attending a best interest meeting on 27 May 2015 in which the doctor says they tried to answer all the questions about Mr D’s medical issues.
  6. Mr D’s clinical notes at various points refer to “small vessel brain disease”, “vascular PD”, “vascular dementia” and “mild cognitive impairment” (MCI). The information provided by Miss D indicates she did not feel she got enough information about how these related to her father and that she still does not know which was the ‘correct’ diagnosis.
  7. I have sought clinical advice from specialists in geriatrics, neurology and psychiatry. Their detailed comments indicate that, in summary, they considered
    • a CT scan of the brain on 27 March 2015 showed the presence of small vessel brain disease,
    • it was not wrong for the hospital staff in charge of Mr D’s care to tell his family he had “small vessel cerebrovascular disease” and “multi-infarcts disease” because that was what was on the scan results and the medical team believed it was contributing to Mr D’s problems,
    • the hospital did not perform an MRI brain scan, despite a neurologist requesting one. However,
    • the overall actions of the geriatrics team in managing the process of investigation/diagnosis were in keeping with good practice and guidance because they asked for a CT brain scan, asked for the relevant blood tests and made an early referral to psychiatry,
    • it is difficult to give a definitive diagnosis in complex cases such as Mr D’s where there is a psychiatric background as well as a possible new diagnosis of dementia,
    • the clinical notes confirm the presence of some cognitive impairment,
    • however, the psychiatry adviser considered there was a lack of clarity around the degree of the impairment and whether it was a type of dementia or a mild cognitive impairment, whereas
    • the neurology adviser considered it was reasonable and in line with diagnostic criteria to conclude the results of the investigations the hospital performed indicated Mr D probably had vascular dementia,
    • any delays, flaws or disagreements in diagnosis did not make a difference for Mr D because
      1. the key issues were assessing capacity and managing behaviour, neither of which depended on a more definitive neurological diagnosis,
      2. there are no specific drugs for vascular dementia. It is managed by assessing the patient’s needs and supporting them in their own home or in residential care. The Medway Trust did this despite the differences in opinion about the degree of Mr D’s cognitive impairment.
  8. Having carefully considered the information on Mr D’s hospital and liaison psychiatry records, as well as the clinical advice, I consider that
    • it was not fault for Medway Trust to tell Mr D’s family he had small vessel brain disease as this is what his scan results indicated,
    • there was a difference of opinion between Medway Trust’s treatment team and Kent Trust’s liaison psychiatry team about the degree of Mr D’s cognitive impairment and whether this meant he had MCI or early vascular dementia,
    • there are enough documentary records to show how Kent Trust reached its diagnosis of MCI,
    • Kent Trust’s records show that its liaison psychiatry team spoke with Miss D, but there is no record of the explanations it gave her about MCI. Kent Trust’s discharge letter to Mr D’s GP does not mention MCI. These were faults,
    • there is not enough documentary evidence to show that Medway Trust carried out all the investigations recommended in relevant guidance before diagnosing early vascular dementia. Medway Trust’s discharge letter also does not mention either MCI or early vascular dementia. These were faults. But I cannot conclude Medway Trust was wrong in considering that Mr D may have had vascular dementia, because the results of the investigations recorded by Medway Trust can all indicate vascular dementia.
  9. The difference of opinions about the degree of cognitive impairment and whether Mr D had any type of dementia did not cause Mr D an injustice. This is because he would not have received significantly different treatment had he had a more definitive diagnosis.
  10. However, Miss D was understandably confused and concerned by the conflicting information she received during her father’s stay in hospital. It would have been good practice for Medway Trust, as the Trust in charge of Mr D’s care during his stay in hospital, to meet with or write to Miss D and explain clearly
      1. the meanings of and differences between the terms ‘small vessel disease’, ‘MCI’, ‘vascular dementia’ and ‘vascular Parkinsonism/PD’,
      2. that doctors were considering MCI or vascular dementia as possible diagnoses based on the information they had so far,
      3. that further investigations would be needed to confirm a definitive diagnosis, possibly following discharge from hospital.
  11. Medway Trust has already apologised to Miss D and her mother for the problems they have experienced during Mr D’s stay in hospital in 2015. This addresses Miss D’s injustice from any faults in communication with her.
  12. I have made recommendations below to ask the Trusts to learn from the faults identified in this case to prevent similar problems from recurring.

Mental capacity assessments and delayed discharge from hospital

  1. Miss D complains that the Council and Medway Trust delayed assessing Mr D’s capacity to decide where he wanted to be discharged to, leading to a delay in hospital discharge.
  2. Medway Trust says Mr D was medically fit for discharge on 1 April 2015 and remained so until he was eventually discharged in October 2015.
  3. Medway Trust did not assess Mr D’s mental capacity for making decisions about discharge.
  4. The Council says it received a request from the Trust for assessment on 1 April 2015 and the Trust advised it Mr D was medically fit for discharge on 12 May 2015.
  5. The following is a summary of the Council’s and Medway Trust’s key actions regarding Mr D’s discharge from hospital. I have compiled this from documentary records provided by the Medway Trust and the Council:
    • on 7 April 2015, a multi-disciplinary team meeting decided a social worker would do a ‘complex needs assessment’ for Mr D,
    • the social worker started assessing Mr D about a month later,
    • following three visits, the social worker completed a mental capacity assessment on 21 May 2015. She concluded he lacked capacity to decide on a safe discharge destination. I have found no fault in this assessment,
    • there was a Best Interest Meeting on 27 May 2015. Present were a social worker, Mrs D, Miss D and hospital staff. They decided that it was in Mr D’s best interest to be discharged to his own home after occupational therapy and physiotherapy assessments. I have found no fault in the conduct of this meeting,
    • between the end of May and early June 2015, Mr D had occupational therapy and physiotherapy assessments which recommended he went into 24-hour residential care because he was at high risk of falls at home,
    • between 5 and 17 June 2015, social workers assessed Mr D’s capacity to decide on a safe discharge destination again. This was because health professionals were recommending residential care and Mr D was strongly against this. Given the time that has passed since the last mental capacity assessment, that Mr D’s condition appeared to change over time and that he was very much opposed to going into residential care, my view is that the Council was correct in reassessing his mental capacity. They concluded Mr D lacked capacity to decide on a discharge destination. I have found no fault in this assessment,
    • on 22 June 2015, the Medway Trust assessed Mr D’s eligibility for NHS continuing healthcare funding and concluded he was not eligible,
    • there was a Best Interest Meeting on 26 June 2015. Present were a social worker, Mrs D, Miss D, Miss D’s advocate and the ward manager. They decided that it was still in Mr D’s best interest to be discharged to his own home. The plan was for Miss D to be Mr D’s main carer because he was unlikely to accept support from agency carers whom he did not know. The Council was going to organise telecare technology and half hour visits from agency carers with the aim of them building up a relationship with Mr D in the hope he would eventually accept more care from them. I have found no fault in the conduct of this meeting,
    • the social worker also completed a ‘long term support assessment’ on 26 June 2015. As well as assessing Mr D’s social care needs, it provided a more detailed plan of the care support the Council would organise for Mr D after he was discharged home. I have found no fault in this assessment,
    • at the beginning of July 2015, Miss D said that she did not think she could cope with caring for Mr D at home. The plan changed to a temporary discharge to a residential care home, which would be reviewed after a while to see if Mr D could return home at a later date. The social worker updated the ‘long term support assessment’ to reflect this,
    • the Council gave Miss D a list of residential care homes on 9 July. By 22 July records indicate Miss D was still looking at this and the social worker had found some care homes that may have been suitable, but none had spaces,
    • between July and September 2015, 14 residential care homes either refused places for Mr D or placed him on their waiting list,
    • on 8 September, one care provider (Home A) offered Mr D a place at a cost of over £1,110 a week, which was about £550 more than the Council’s usual rate. Mr D was third on a waiting list for another nursing home (Home B) that was less expensive. The Council decided to expand its search. Home C, whose fees were close to the Council’s usual rate, agreed to assess Mr D on 9 September. Miss D declined Home C because of its poor CQC report. Mr D’s family could not afford to pay a ‘top up’ to Home A’s weekly rate. The Council continued to search for providers who charged at the Council’s usual rate. The Council did not act with fault in looking for a provider that was less expensive than Home A. This is because other more affordable providers considered they could meet his needs,
    • on 23 September 2015, the Council completed another ‘long term support assessment’ and recommended 24-hour residential care. Around the same time, the Council also became aware that there was an injunction prohibiting Mr D from having contact with Mrs D. The injunction expired in January 2016, unless Mrs D took legal action to get it rescinded,
    • on 24 September 2015, the Council formally assessed Mr D’s capacity to decide on a safe discharge destination again. The Council was correct in reassessing his mental capacity because of the time that had passed since the last assessment. The Council concluded Mr D now had capacity to decide on a discharge destination. I have found no fault in this assessment,
    • on 1 October 2015, Copper Beeches care home, offered Mr D a place from 12 October. The social worker who completed the assessments of 23 and 24 September recorded that Mr D agreed with being discharged to Copper Beeches care home with a view to returning home at some stage.
  6. I consider that:
    • there were no faults by Medway Trust and Kent Trust that delayed Mr D’s discharge from hospital,
    • there was an unexplained delay of about a month between the Council being aware that Mr D needed a social care assessment in April 2015, and starting the assessment in May. This delay between April and May was fault by the Council. It has contributed to the overall delay in discharging Mr D from hospital. I have made recommendations below to address this,
    • the Council and Medway Trust took about two months between May and June 2015 to complete mental capacity, social care, occupational therapy and physiotherapy assessments. Because Mr D’s behaviour and ability to understand and take part fluctuated, these took place over several sessions and consequently took a long time. However, I have found no fault in the assessments and the time taken to complete them was not fault,
    • by the end of June 2015, Mr D was very nearly discharged to his own home on the understanding that Miss D would be his main carer. However, she felt unable to do this and so the Council had to look for residential care. So, delay between May and June 2016 also happened because the Council and Medway Trust were working on the assumption Mr D would be going to his own home,
    • between 2 July and 1 October 2015, the Council was looking for a care home that would accept Mr D, had vacancies, and was within the Council’s usual rate. The time it took to do this was not fault because there is evidence the Council actively searched for a suitable nursing home and contacted many providers before one that was acceptable to the family agreed to accept Mr D.

Placement in Copper Beeches care home

  1. Miss D says that
    • she did not want Mr D to go into Copper Beeches care home because it had a poor rating from the Care Quality Commission (CQC – the organisation that inspects health and social care services)
    • Copper Beeches care home was inappropriate for Mr D because there was no entertainment for him, the behaviour of other residents disturbed his sleep and the Home felt he did not need 24-hour care
    • the family had no say in Mr D’s placement at Copper Beeches care home and felt almost blackmailed into the arrangements
    • the Council offered only one alternative to Copper Beeches care home, which had an even worse CQC rating.
  2. The Council says it considered a discharge to a temporary stay in residential care was the best option as there were concerns about Mr D returning to his own home because
    • a restraining order was in place that said he should not live in the same property as his wife and police had confirmed he could not return home
    • Mr D had been neglecting himself just before going into hospital
    • he would not be able to manage the 25 steps he needed to climb to get into the house
    • Mrs D had said she was going to put the house on the market. Social workers were concerned potential buyers could disturb and agitate Mr D when viewing the house.
  3. Miss D disputes that Mr D could not return to his own home from hospital due to the risk of falls and the other concerns identified by the Council. She says Mr D could use the stairs with help when he returned home in December 2015. She also says Mr D was reconciled with Mrs D and living in the same house despite the injunction.
  4. The following is a summary of the Council’s key actions regarding Mr D’s placement in Copper Beeches care home. I have compiled this from documentary records provided by the Council:
    • after Miss D reported she no longer felt able to care for Mr D at home, the social worker reviewed his medical and social history and his current needs. The social worker requested a nursing home place because Mr D’s prostate cancer and bone metastases may deteriorate. The social worker said a conventional nursing home was not appropriate because of Mr D’s verbal and physical aggression, which would benefit from specialist carers,
    • other than Home A (which cost about twice the Council usual rate), and Home C (which Miss D rejected due to poor CQC reports), Copper Beeches care home was the only care provider that would offer Mr D a place,
    • Council records state that, in October 2015, Miss D had told social workers that she wanted Mr D to go to Copper Beeches care home,
    • Copper Beeches care home itself questioned whether it was a suitable placement for Mr D soon after he moved there. Copper Beeches care home felt that Mr D did not need the same level of care as its other residents, who had significant needs due to dementia. Mr D, who had capacity to decide about where to live, was also saying he would like to go home,
    • in response to concerns from Copper Beeches, the Council looked into supporting Mr D to move back to his own home or to move to a different care home,
    • until December 2015, police advice to the Council was that the injunction prevented Mr D from living in the same house as Mrs D,
    • the police advised the Council on 7 December 2015 that the restraining order had been discharged early following a court application by Mrs D.
    • Mr D moved back to his own home on 9 December 2015.
  5. The records I have seen indicate that ideally, Mr D would have been discharged to his own home. However,
    • Mr D needed support with his care and with using stairs,
    • he was unlikely to accept support from strangers or his wife,
    • Miss D did not feel able to care for him at home from July to October 2015,
    • even if Miss D had felt able to support Mr D, until December 2015, there was a court injunction preventing him from returning home if Mrs D lived there,
    • although Mr D was physically much more able by October 2015 than he had been in April, he was still at risk of falling, needed help with food and drink preparation, and had recently been violent towards patients and staff in hospital,
    • the Council considered that a standard residential care home would not be suitable because of his aggression. It also considered that a residential care home specialising in older people’s mental health needs was unsuitable because his aggressive outbursts were unpredictable,
    • the Council concluded a nursing home specialising in older people’s mental health needs was more suited to Mr D’s needs because it would have higher staffing levels and staff trained to manage aggressive behaviour. It also considered a nursing home would be the best place to manage his risk of falls and any worsening in the progress of his prostate cancer.
  6. Taking all this into account, I have concluded that the Council did not act with fault in planning for Mr D to be discharged to a specialist nursing care home. Copper Beeches care home was the only care provider with space that was within the Council’s budget and was acceptable to Mr D’s family. Therefore, the Council did not act with fault in supporting a move from hospital to Copper Beeches care home at this point.
  7. When Copper Beeches care home raised concerns about its suitability for Mr D, the Council considered supporting Mr D to move to his own home. The police then told the Council that the restraining order meant Mr D could not contact his wife directly or indirectly and prevented him from returning home while she lived there. The Council concluded it could not support Mr D with returning home while the restraining order was in place. The Council did not act with fault in taking this view.
  8. The Council considered looking for other care homes, where the other residents did not have such advanced dementia, while Mr D’s wife took steps to get the order revoked. It decided Mr D was unlikely to be accepted by ‘standard’ care homes because he had recently attacked a carer in Copper Beeches care home. It also considered that any other care homes that might accept him would be no more suitable than Copper Beeches. There was no fault in the Council not seeking a different residential placement while waiting for Mr D’s and the courts to revoke the restraining order.
  9. The pre-admission assessment document that Copper Beeches completed before Mr D left hospital has very little written on it to show how and why Copper Beeches considered it could meet Mr D’s needs. In light of Copper Beeches’ concerns about its own suitability for Mr D as soon as he moved there, I consider that Copper Beeches, acting on the Council’s behalf, was at fault in not properly assessing whether it was suitable for Mr D’s needs before he left hospital.
  10. Copper Beeches’ records indicate that, for much of his time there, Mr D appeared content and relaxed. So, Mr D did not suffer a significant injustice as a result of any faults in the pre-admission assessment. I have made recommendations below, to address possible injustice to others.

Care of Mr D at Copper Beeches

  1. Miss D says
    • Copper Beeches did not give Mr D enough food and drink, and the food he got was of a poor quality so he went hungry,
    • there was no entertainment in Copper Beeches,
    • Mr D’s family had to shower him and change his bed linen,
    • Mr D’s sleep was disturbed because of other residents’ behaviour.
  2. Copper Beeches’ records show that
    • Copper Beeches asked Mr D what his favourite foods and drinks were, and whether there were any he wanted to avoid. Copper Beeches completed a ‘Malnutrition Universal Screening Tool’ (MUST) when he moved there. This indicated he was at low risk of malnutrition. Copper Beeches also attempted to weigh Mr D three times. He gained just over a kilogram in weight in the first four weeks of his stay there. He refused a weight check in mid-November and the Home did not try to weigh him again before he left in December 2015. This was not fault as Copper Beeches checked his weight once a month, as indicated by the MUST score.
    • Daily care notes also indicate Mr D consumed varied food and drinks in reasonable amounts, although there were times he refused a meal. There is no documentary record of him complaining about the quality of the food or the choice of meals. There is one record of Miss D telling the Council she felt that an assault on a member of staff was because of poor quality food.
    • The care notes indicate Mr D slept well at the beginning of his residence, but by early November was sleeping less well, probably because of hourly night time checks by care staff. In response, Copper Beeches reduced the night time checks to once a night at the beginning of a night shift and ensured his bedroom door was kept closed.
    • The care notes as a whole indicate Mr D preferred to spend time with his family, and when they were not there, preferred to spend time alone in his room. Daily care notes indicate he was usually happy and relaxed doing this, and did not welcome intrusion from staff or other residents.
  3. Having carefully considered the information provided by Miss D, the Council and Copper Beeches, I have concluded that Copper Beeches complied with Regulations and did not act with fault when caring for Mr D. In particular, the information I have considered indicates that Copper Beeches
    • provided Mr D with person-centred care and respected his wishes about how he wanted to spend his time there
    • treated Mr D with dignity and respect
    • met his needs for food and drink.

Back to top


  1. To ensure that it is issuing A&E discharge letters whenever appropriate, the Trust should, within two months of the date of my final decision
    • review its current arrangements for issuing A&E discharge letters,
    • if the review identifies problems, implement an action plan to resolve those problems,
    • provide evidence to the Ombudsmen that it has complied with this recommendation.
  2. To ensure record keeping about falls is accurate and complies with guidance, the Trust should, within two months of the date of my final decision
    • remind staff of the need to follow the falls policy and maintain accurate records,
    • ensure all clinical staff who may need to complete post falls checklists are competent in all aspects of doing so,
    • ensure it has robust systems to monitor compliance with all aspects of its falls policy,
    • ensure nursing staff are aware of requirements for contacting family and documenting this,
    • provide evidence to the Ombudsmen that it has complied with these recommendations.

Medway Trust and Kent Trust

  1. To learn from the problems I have identified with record keeping and communication about diagnoses, the two Trusts should, within two months of the date of my final decision, share the decision with the teams involved in caring for Mr D and ask them to reflect on the impact on patients and their families of poor record keeping and communication about diagnoses.


  1. To avoid unnecessarily delaying other hospital discharges, the Council should, within two months from the date of my final decision
    • review its current arrangements for dealing with hospital referrals for adult social care assessments,
    • if the review identifies problems, implement an action plan to resolve those problems,
    • provide evidence to the Ombudsmen that it has complied with this recommendation.
  2. To avoid placing people in residential care that is inappropriate for their needs, and where they may pose an unrecognised risk to others, the Council should, within two months from the date of my final decision,
    • review its current arrangements for ensuring Copper Beeches and any other residential care providers it commissions carry out adequate pre-admission assessments
    • if the review identifies problems, implement an action plan to resolve those problems,
    • provide evidence to the Ombudsmen that it has complied with this recommendation.

Back to top

Final decision

  1. The Council and two Trusts have accepted my recommendations. I have now completed my investigation and close the complaint.

Back to top

Investigator's decision on behalf of the Ombudsman

Print this page