Dudley Group NHS Foundation Trust (16 018 546c)

Category : Health > Hospital acute services

Decision : Not upheld

Decision date : 23 Jan 2018

The Ombudsman's final decision:

Summary: Ms A complains about the care, support and treatment her mother received from a Council, GP practice and four hospitals from November 2015 to May 2016. The Ombudsmen find no fault in the actions of these organisations.

The complaint

  1. Ms A complains about the care, support and treatment her late mother, Mrs R, received from November 2015 to May 2016. She complains about:
  • Sandwell Metropolitan Borough Council (the Council) and Warrens Hall Care Home (the Care Home), which the Council funded while Mrs R stayed there
  • Oldbury Health Centre (the Practice)
  • Dudley Group NHS Foundation Trust (Dudley Trust)
  • Royal Wolverhampton Hospital NHS Trust (Wolverhampton Trust)
  • Sandwell and West Birmingham Hospitals NHS Trust (Sandwell Trust).
  1. Ms A complains:
  • The Council did not arrange enough support to care for Mrs R at home after she went into the Care Home. Ms A complained the Council did not ‘help to give me a break even for one night a week’.
  • The Care Home and the Practice failed to give Mrs R oxygen while she was in the Care Home. Mrs R stayed in the Care Home from 9 November 2015 to 11 January 2016. Ms A said neither the Care Home nor the Practice arranged oxygen for Mrs R. She said Mrs R had to go to hospital due to low oxygen saturations.
  • The Council failed to arrange for Mrs R to move to sheltered accommodation while she was in Russells Hall Hospital. Mrs R was an inpatient at Russells Hall Hospital (part of Dudley Trust) from 11 January to 9 February 2016. Ms A said she found sheltered accommodation in Wolverhampton for Mrs R. Ms A said the Council would not let her take this accommodation and have not explained why.
  • The Council and Dudley Trust failed to arrange oxygen for Mrs R to use at home when she left Russells Hall Hospital. Mrs R left Russells Hall Hospital on 9 February 2016. Ms A said professionals did not provide home oxygen. She said this left Mrs R gasping for breath. Ms A said she had no choice but to call an ambulance to take Mrs R back to hospital on 10 February 2016.
  • New Cross Hospital gave Mrs R end of life medication. Mrs R was in New Cross Hospital (part of Wolverhampton Trust) from 10 to 24 February 2016. Ms A said that, as far she could recall, this was when staff started to administer end of life drugs to Mrs R. Ms A complains this was wrong.
  • Wolverhampton Trust and the Council failed to provide necessary equipment and follow-up when Mrs R left New Cross Hospital. Mrs R left New Cross Hospital on 24 February 2016. Ms A said staff did not provide oxygen or a suitable mattress. Ms A said her mother screamed in agony in the middle of the night after she left hospital. In addition, Ms A said no one arranged for community nurses to check on Mrs R.
  • An ambulance crew dropped Mrs R from a stretcher. Mrs R went into A&E on 15 March 2016. A private ambulance company took her home late at night. Ms A said the crew dropped Mrs R from the stretcher to the floor which caused her pain and left her with bruising.
  • The Council and Practice admitted Mrs R to Sandwell Hospital for end of life care but lied about the reason for the admission. Mrs R went into Sandwell Hospital (part of Sandwell Trust) on 18 March 2016. Ms A said a Social Worker and GP told her they had arranged for Mrs R to go into hospital for rehabilitation. Ms A said, in fact, they put her in hospital for end of life care.
  • Sandwell Hospital put Mrs R on an end of life pathway. Mrs R was in Sandwell Hospital from 18 March to 8 April 2016. Ms A said Mrs R knew what the hospital were doing and this upset her as she did not want to end her life that way. Ms A said professionals did not listen to their requests to treat Mrs R.
  • Sandwell Trust kept Mrs R in Sandwell Hospital for too long. Mrs R left Sandwell Hospital on 8 April 2016. Ms A said Sandwell Hospital only agreed to let Mrs R leave after she called, wrote to and tweeted the executive office.
  • City Hospital put Mrs R on an end of life pathway. Mrs R was in City Hospital (also part of Sandwell Trust) from 25 April to 7 May 2016. Ms A said the decision to treat Mrs R in this way was wrong.
  • Sandwell Trust kept Mrs R in City Hospital for too long. Mrs R left City Hospital on 7 May 2016. Ms A said City Hospital ignored her requests to discharge Mrs R.

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What I have investigated

  1. I have investigated Ms A’s complaints about the Council, the Practice, Dudley Trust, Wolverhampton Trust and Sandwell Trust. I have not investigated Ms A’s complaint about the ambulance crew. The final section of this statement contains my reasons this.

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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 will not generally investigate a complaint unless they are satisfied the matter has been brought to the relevant organisation’s attention and that organisation has had a reasonable opportunity to investigate and reply to the complaint (Local Government Act 1974 section 26(5), as amended and Health Service Commissioners Act 1993, section 9(5)). However, in the case of joint complaints (i.e. those deemed suitable for investigation by the Joint Working Team operated by both PHSO and LGSCO), if one organisation has investigated and replied to the complaint but another organisation has not, the Ombudsmen may decide to exercise their discretion to investigation the complaint against all organisations, so that the issues can be considered in the round.
  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. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe any of the following:
  • it is unlikely they would find fault
  • the fault has not caused injustice to the person who complained
  • the injustice is not significant enough to justify their involvement
  • it is unlikely they could add to any previous investigation by the bodies
  • they cannot achieve the outcome someone wants
  • there is another body better placed to consider this complaint
  • it would be reasonable for the person to ask for a review or appeal

(Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended).

  1. 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.
  2. 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)).

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How I considered this complaint

  1. I read the correspondence Ms A sent to the Ombudsmen and asked her about her concerns via email. The Council had replied to a complaint from Ms A and I read the letters relating to this, along with the Council’s records.
  2. The other organisations had not investigated Ms A’s concerns before she came to the Ombudsmen. We exercised discretion to look at the whole of the case, as a way of looking at this complex sequence of events in the round. I wrote to all the organisations to explain what I intended to investigate and to ask for comments and copies of relevant records. I considered all the comments and records they provided.
  3. I read relevant legislation and guidance and got advice from three clinical advisers: a GP, a Respiratory Consultant and a Nurse.
  4. I shared a confidential copy of my draft decision with Ms A and all the organisations to explain my provisional findings. I invited their comments on this and considered the responses I received.

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What I found

  1. Health and social care staff should presume people have the mental capacity to make choices about their own care unless there is proof to the contrary. This is set out in the Mental Capacity Act 2005 and the Code of Practice. If a person lacks mental capacity to make a particular choice, a decision must be made in their best interests.

Hospital discharge

  1. Leaving hospital after an inpatient stay is part of a process, and not an isolated event. Planning should start at the earliest opportunity, and it should involve health and social care staff in the hospital and community working together. The process should lead to a personalised plan for each patient who is leaving hospital. Good discharge planning should help patients leave hospital safely, without delay and with suitable support ready in the community. The key guidance about this is the Department of Health’s Ready to go? Planning the discharge and transfer of patients from hospital and intermediate care, published in 2010.

End of life care

  1. People are considered to be approaching the end of their life when they are likely to die within the next 12 months. When professionals feel a person has reached this point they should start planning to ensure the person receives appropriate support throughout this time. This is different from the care of people who are dying and are in the last days of their life. Caring for people who are dying can involve giving them medication to help control pain, anxiety, sickness and other distressing symptoms.

Complaint the Council did not arrange enough support to care for Mrs R at home after she went into the Care Home

Events leading to November 2015

  1. Mrs R had several long‑term health problems, including:
  • Obesity Hypoventilation Syndrome – a breathing problem that leads to low oxygen levels and too much carbon dioxide in the blood
  • Chronic Obstructive Pulmonary Disease (COPD) – a name for a group of lung conditions that cause breathing difficulties
  • Type 2 diabetes – a condition which causes a person’s blood sugar level to become too high
  • High blood pressure – a condition that increases the risk of serious conditions including stroke and heart attack.

Mrs R also had difficulty moving around on her own and was doubly incontinent.

  1. Mrs R lived in a privately rented house. She lived in one downstairs room and stayed in bed during the day and night. The Council provided support for Mrs R. It initially paid for carers from an agency. From February 2015 the Council gave Mrs R money which she used to employ a personal assistant who visited four times a day. Ms A also supported her mother.
  2. From 2014 Ms A raised concerns that Mrs R’s rented house was not suitable and Mrs R was not safe there. Ms A felt Mrs R should live in an Extra Care facility. However, Mrs R said she wanted to live with a family member.
  3. Toward the end of June 2015 Mrs R’s Social Worker visited Mrs R to review her needs and support. Circumstances prevented the Social Worker completing the review. The Social Worker said she would rearrange the review. In the following weeks Ms A called the Council but the Social Worker was off sick.
  4. On 13 July 2015 Ms A told the Council she would like a night carer as she had been staying up with Mrs R but was too tired to continue. The Council said it could not provide a night sitter but said it could pay for some temporary respite, if Mrs R agreed to this.
  5. On 6 August 2015 Mrs R’s case was ‘deallocated’ from a named Social Worker. In an internal note the Social Worker said the review she tried to complete at the end of June 2015 still needed to be done. The Council noted its duty team would manage the case until it could be assigned to an available worker for review.
  6. Ms A continued to contact the Council regularly and asked for help to find more suitable accommodation for Mrs R. Ms A also repeated that she could no longer cope in her caring role. On 13 August 2015 a Psychiatrist wrote to the Council, having reviewed Mrs R. The Psychiatrist said Ms A used to live with Mrs R but was under great stress due to the level of her mother’s care needs and had moved to a rented room. In the middle of September 2015 an ambulance service referred Mrs R to social services owing to concerns about whether she had enough care. A Social Worker visited Mrs R at the end of September 2015. Mrs R said she wanted to move to London to live with her family. She said she did not want to live in a flat where she had to live with others, and did not want to view an Extra Care housing facility or another flat.
  7. In early October 2015 Ms A called the Council and said she could not cope with caring for Mrs R any more as she worked all day and could not look after her as well. Ms A said Mrs R kept being turned down for alternative accommodation. She asked for respite to allow time for more suitable accommodation to be found. Later in October a Social Worker visited Mrs R and Ms A and discussed Extra Care housing. The Social Worker said the Council could arrange respite while work was carried out on Mrs R’s property but not until Ms A arranged alternative accommodation. At the end of the month the Council paid for a two week respite placement for Mrs R.

Mrs R’s stay in the Care Home from November 2015 to January 2016

  1. Mrs R went into the Care Home on 9 November 2015. Ms A told the Council it would be wrong for Mrs R to return home. She said the boiler was broken and listed a range of other problems with the house. Ms A told staff again that she wanted Mrs R to go to alternative accommodation. Staff at the Council said it was not possible to arrange this in two weeks. They also said Mrs R would have to agree to it and sign a tenancy agreement before she could move.
  2. A Council Housing Officer wrote to the private landlord about making improvements to the house, including fixing the boiler. The Council also suggested Ms A contact a service (Warm Zone) which might be able to help while this work happened.
  3. On 30 November 2015 a Councillor called social services on Ms A’s behalf and asked for more support. The Council asked if Ms A wanted an increase in Mrs R’s package of care, or if she wanted a carer’s assessment. The Councillor said Ms A wanted a Social Worker to visit more often.
  4. Mrs R remained in the Care Home beyond the two week period the Council agreed to fund. She left the Care Home and went to Russells Hall Hospital on 11 January 2016, nine weeks after her admission. Later in January 2016 the Council agreed to pay for the entire cost of Mrs R’s stay in the Care Home.

Analysis

  1. It is clear from the Council’s records that, before Mrs R went into the Care Home, Ms A was in regular contact and often said she was struggling to cope and wanted more help and support to care for Mrs R’s needs. It is notable that the Council planned to review Mrs R in June 2015 and were not able to but did not rearrange a review. Further, I have not seen any evidence of a carer’s assessment in the file which, again, seems notable in the context of Ms A’s repeated statements that she could no longer cope.
  2. However, I have not seen any evidence to show that Ms A asked for an increase in Mrs R’s package of care, or a carer’s assessment, during Mrs R’s admission to the Care Home. It is also evident that professionals felt Mrs R was able to make her own choices about her care, and where she lived, and took these into account.
  3. The Council agreed to fund Mrs R’s place in the Care Home for considerably longer than the original agreement. During Mrs R’s stay in the Care Home the Council got in touch with the private landlord, and offered advice about finding Extra Care housing. Overall, have not found fault on the part of the Council during this time.

Complaint the Care Home and the Practice failed to give Mrs R oxygen while she was in the Care Home

Use of oxygen before November 2015

  1. An assessment of Mrs R’s needs took place when she was in hospital in November 2014. It noted Mrs R had long‑term oxygen at home and had used oxygen on the ward. A Council assessment in December 2014 also noted Mrs R used oxygen. However, the assessment said Mrs R would ‘at times remove the mask for a considerable time and seems unable to understand that she needs to wear the mask all of the time to assist with her health condition’. An assessment in March 2015 said Mrs R had ‘Oxygen as and when needed’. However, notes in March 2015 from an out of hours doctor, a GP, a social worker and other professionals reported that Mrs R was not using the oxygen. In August 2015 a GP wrote to the oxygen supplier and said that Mrs R no longer needed it at home.

The Care Home’s assessment of Mrs R’s needs

  1. Staff from the Care Home completed several assessments when it admitted Mrs R. The Care Home noted Mrs R had COPD but was not prescribed oxygen. It also noted that Mrs R could let people know when she was in pain or distress.

Events during Mrs R’s admission to the Care Home

  1. Staff in the Care Home kept daily records of what they did for Mrs R, and about how she was. These notes contain frequent entries about Mrs R eating and drinking, references to her refusing care, refusing medication and shouting and hitting out at staff. The daily records also contain notes about Mrs R asking for things from staff (such as for her window to be opened, or for the heating to be turned on). Staff also kept other types of daily records, to keep track of her health and wellbeing.
  2. A GP examined Mrs R on 10 December 2015 and measured her oxygen saturation levels. The GP increased a dose of medication. On 12 December 2015 staff noted Mrs R was breathless when she was agitated. They checked her oxygen levels and found they were satisfactory.
  3. On 14 December 2015 Ms A told staff that Mrs R seemed breathless. The following day staff noted that Mrs R’s breathing sounded different. They measured her oxygen levels and contacted the GP. A GP examined Mrs R on 16 December 2015. They again made some changes to her medication.
  4. Care home staff began recording observations every two hours on 17 December. These records do not record concerns about Mrs R’s breathing.

Events on 10 and 11 January 2016

  1. Staff noted Mrs R seemed unwell late on 10 January 2016. They checked on her regularly and called an ambulance. Mrs R at first refused to go to hospital but later agreed. When paramedics tried to give her oxygen she took the mask off.
  2. Mrs R got to Russells Hall Hospital in the early hours of 11 January 2016. Staff noted she refused to keep an oxygen mask on. Later in the evening of 11 January medical staff were happy that Mrs R no longer needed to be in hospital.

Analysis

  1. The records show Care Home staff properly considered Mrs R’s breathing needs when it took on her care. There was nothing to show she needed oxygen at that time.
  2. The Care Home’s records show staff checked on Mrs R’s often enough to keep an eye on her general health, including her breathing. The records also show that staff recorded Mrs R’s oxygen levels when they were concerned about her seeming breathless, and asked for help from the GP (or other sources of medical advice) when they had concerns. The GPs, in turn, examined Mrs R properly.
  3. Mrs R’s condition changed suddenly and unpredictably on the night of 10 January. The Care Home’s staff could not have predicted this, and nor could the GPs during their visits. There is no evidence to show that the Care Home or Practice should have arranged oxygen for Mrs R during this time. When Mrs R did become unwell staff got medical support and kept regular observations. This was appropriate. Therefore, I have not found any evidence of fault on the part of the Care Home or the Practice.

Complaint the Council failed to arrange for Mrs R to move to sheltered accommodation while she was in Russells Hall Hospital

Events during Mrs R’s admission to Russells Hall Hospital

  1. Before Mrs R went into hospital, on 8 January 2016, Ms A emailed the Council and said she wanted her mother to move out of the Care Home as soon as possible. She said she had found a place in the Wolverhampton area.
  2. Dudley Trust told the Council Mrs R was medically ready to leave hospital on 12 January 2016. However, it said Ms A did not want her to go back to the Care Home. The Council called Ms A the same day. Ms A said she had found a place in Wolverhampton and had the keys and was ready to move in. She said she wanted Mrs R to stay in hospital while the Council arranged some care in Wolverhampton. The Council said Wolverhampton Council would have to arrange the necessary care. It said it would help by getting in touch with Wolverhampton Council and passing on relevant information. The Council referred the case to Wolverhampton Council on 15 January, and sent more information on 19 January.
  3. Wolverhampton Council visited the ward and assessed Mrs R on 3 February 2016. However, Mrs R said she wanted to go back to her old rented property, in the Council’s area. The following day Mrs R’s support worker told the Council Ms A wanted Mrs R to go and live with her in Wolverhampton. The Council got in touch with Wolverhampton Council and Russells Hall Hospital and explained the plan was again for Mrs R to go to Wolverhampton.
  4. Mrs R left Russells Hall Hospital and went to Ms A’s rented property in Wolverhampton on 9 February 2016.

Analysis

  1. I have not seen any evidence to show the Council stood in the way of any plans to discharge Mrs R to the location of her choice. There is evidence to show it liaised with Wolverhampton Council, the hospital and Mrs R’s support worker appropriately to help her move to Wolverhampton. Therefore, I have not found any evidence of fault.

Complaint the Council and Dudley Trust failed to arrange oxygen for Mrs R to use at home when she left Russells Hall Hospital

Events during Mrs R’s admission to Russells Hall Hospital

  1. Russells Hall Hospital treated Mrs R with oxygen, although it planned to wean her off this. Nursing entries show that Mrs R regularly took her oxygen mask off.
  2. In late January doctors referred Mrs R to the Dudley Respiratory Assessment Service (DRAS), to ask whether she would need oxygen at home. A doctor from DRAS reviewed Mrs R on 9 February 2016. They concluded that Mrs R could go home without oxygen, and DRAS would review the situation in six weeks.

Events on 9 and 10 February 2016

  1. Mrs R left Russells Hall Hospital on 9 February 2016 and moved to a rented property in Wolverhampton. However, the following morning carers called an ambulance as Mrs R was agitated and short of breath. The ambulance took Mrs R to New Cross Hospital. Late in the evening staff noted Mrs R was visibly short of breath. New Cross Hospital admitted Mrs R and planned to treat her with as little oxygen as possible.

Analysis

  1. It was Dudley Trust’s responsibility to decide if Mrs R needed oxygen when she left Russells Hall Hospital, and to arrange it if she did. The Council did not have any responsibility here.
  2. The records show that medical staff considered Mrs R’s long‑term conditions and monitored how well she responded to treatment while she was in hospital. The medical team got advice from a more specialist team to help decide whether to arrange home oxygen. That team, in turn, based its advice on relevant information. Therefore, there is evidence to show Dudley Trust gave this issue proper consideration. The decision it made was in line with what doctors knew at that time, and in keeping with established good practice. I have not found any evidence of fault.

Complaint that New Cross Hospital gave Mrs R end of life medication

Events during Mrs R’s admission to New Cross Hospital

  1. Mrs R was in New Cross Hospital from 10 to 24 February 2016. The notes show that medical staff considered what they would and would not do to try to treat her. They decided it would not be helpful to attempt intensive, invasive treatment. This was because they felt Mrs R’s symptoms were predictable and irreversible consequences of her long-term health problems. As such, they decided that any intensive treatment would not help Mrs R get better and would only make her distressed.

Analysis

  1. New Cross Hospital thought about what it would do and would not do if Mrs R’s health got worse. It is good practice for hospital doctors to plan in this way. I have not found any evidence of discussions about palliative care. Further, I have not seen any evidence that New Cross Hospital either prescribed or used any ‘end of life medication’ during Mrs R’s admission. Therefore, I find no fault.

Complaint that Wolverhampton Trust and the Council failed to provide necessary equipment and follow-up when Mrs R left New Cross Hospital

Events during the admission to New Cross Hospital – Oxygen

  1. During Mrs R’s time in New Cross Hospital, on 18 February 2016, a doctor noted they planned to try and wean her off oxygen and send her home without it, if they could. However, this was not possible. Staff requested home oxygen on 24 February 2016. Ms A called the ward the same evening and said the oxygen had arrived.

Events during the admission to New Cross Hospital – Equipment

  1. Ms A told staff she wanted to take Mrs R home as soon as possible, on 13 February 2016. She said Mrs R would need a hospital bed and foam mattress.
  2. On 17 February 2016 staff completed a Continuing Healthcare (CHC) Checklist. This recommended a full assessment. Staff sent details of this to the local Clinical Commissioning Group and the Council.
  3. The following day staff requested a bed and mattress for Mrs R. On 22 February 2016 Ms A said she was desperate to take Mrs R home and said that a new bed and mattress were now in place. The next day Ms A said she wanted to take Mrs R home that day.
  4. A nurse advised against this, noting it would not allow time to arrange care for Mrs R. Ms A said she understood and wanted to take Mrs R home. Later, a member of staff from the Council spoke to Ms A and advised against taking Mrs R home. They said no one had been assess the house, and the CHC assessment had not been done. They said it would be better to wait for these things to be done so Mrs R would get the most appropriate package of care. Ms A said this could happen once Mrs R was at home. Mrs R left New Cross Hospital on 24 February 2016.

Analysis

  1. The records from New Cross Hospital provide evidence that staff ordered oxygen for Mrs R’s return home. They also show Ms A confirmed it was there before staff arranged transport to take Mrs R home.
  2. Notes from New Cross Hospital and the Council show that health and social care staff were trying to arrange the things Mrs R needed before she went home. They advised Ms A against taking Mrs R home before they had completed all the relevant steps. This included an ‘access visit’ which would have involved a member of staff visiting the Mrs R’s home to make sure all the necessary equipment was in place, or had been ordered. Ultimately, staff respected Mrs R’s and Ms A’s wishes and Mrs R went home before this happened. It is normal for assessments to take some time to complete, and I have not seen any evidence of unreasonable delays on the part of Wolverhampton Trust or the Council. Therefore, I had not found any evidence of fault here.

Complaint that the Council and Practice admitted Mrs R to Sandwell Hospital for end of life care but lied about the reason for the admission; and

Complaint that Sandwell Hospital put Mrs R on an end of life pathway

Relevant events in 2015

  1. Toward the end of June 2015 iCares (a community service that tries to help people with long‑term conditions) called the Council and said it had visited Mrs R but ‘she has refused input each time’. They said they were ending their service as Mrs R did not want their help. A Social Care update in August 2015 noted that Occupational Therapy and Physiotherapy assessed Mrs R but she would not use the aids they provided and she preferred to stay in bed.

Events in the community after Mrs R left New Cross Hospital

  1. Mrs R left New Cross Hospital on 24 February 2016. A Specialist Nurse Practitioner (from the Practice) spoke to Ms A on 1 March 2016. The nurse noted Ms A wanted Mrs R to have physiotherapy. The nurse said Mrs R had not engaged with this in the past but referred her the same day.

Admission to Sandwell Hospital from 2 to 7 March 2016

  1. The following day a GP reviewed Mrs R at home. They felt she was not safe at home and needed 24 hour care. The GP called an ambulance which took Mrs R to hospital. A doctor reviewed Mrs R in hospital the next day and then spoke to Ms A. They doctor said they could try to treat Mrs R with non-invasive ventilation. However, they said that should be the limit of treatment. The doctor said if it did not work they should consider a palliative approach. The doctor also wrote that Ms A ‘understood that [Mrs R] may die during this admission’. Staff in the hospital completed a ‘Do Not Attempt Resuscitation’ (DNAR) form and placed this on Mrs R’s file.
  2. The hospital gave Mrs R oxygen but staff regularly recorded that Mrs R removed it. A doctor discussed the case with a Respiratory Consultant who noted that Mrs R could go home with long-term oxygen if needed. Mrs R went home on 7 March 2016.

Events in the community from 7 to 18 March 2016

  1. A GP visited Mrs R the next day and noted a DNAR was in place. They also noted that Ms A said she understood and agreed with it.
  2. On 9 March 2016 Ms A spoke to the Council and said Mrs R would benefit from a rehabilitation bed. She said this would help Mrs R regain her mobility and strength. On the same day a GP spoke to the iCares service. iCares noted it had assessed Mrs R in the past but she had not worked with them or done what they suggested. Therefore, it said Mrs R would not be suitable for intermediate rehabilitation care. A GP spoke to Ms A the next day and explained what the iCares team had decided.
  3. In the following days members of staff from the Practice, Council and iCares spoke to each about Mrs R, and arranged a multi-disciplinary meeting for 21 March 2016. Before this meeting could take place, on 18 March, a GP visited Mrs R and did not feel she was safe with her current level of care. The GP arranged an ambulance with took Mrs R to hospital.

Decisions about Mrs R’s care while she was in Sandwell Hospital from 18 March to 8 April 2016

  1. On the day of Mrs R went into hospital staff again decided that non‑invasive ventilation would be the limit of the treatment they would attempt. They decided that intensive care would not be appropriate.
  2. A multi-disciplinary meeting took place, as planned, on 21 March 2016. A GP, Specialist Nurse Practitioner, Social Worker, Community Matron and Physiotherapist attended. They agreed that Mrs R needed 24 hour care which could not be provided in her own home.
  3. Two days later a Best Interests meeting took place in Sandwell Hospital, to discuss Mrs R’s health and what should happen when she left hospital. A Community Matron noted that Mrs R would not engage in rehabilitation so there was no potential for this to help her. The Consultant noted Mrs R’s medical conditions and recent health. He said Mrs R’s lung condition had got worse and said that she was not going to get better as her problems were untreatable. The Consultant said they felt Mrs R was coming to the end of her life. They said it would be right to focus on keeping her as comfortable as possible, rather than attempting things that would be painful or distressing. The notes of the meeting recorded that Ms A agreed with this plan. However, a record from later in the day said Ms A felt her mother should not be having palliative care, and should be treated.
  4. An Associate Medical Director spoke to Ms A on 24 March 2016 and said it appeared Mrs R was in the last year of her life. They recorded that Ms A was aware that Mrs R may not survive longer than weeks or months.
  5. On 29 March 2016 a member of the Macmillan Therapy Team reviewed Mrs R. They suggested the medical team consider using the Supportive Care Pathway and referring her to the Community Palliative Care Team. A doctor spoke to Ms A about the Supportive Care Pathway the same day. They said Mrs R had a progressive, incurable illness and was becoming more frail and more unwell and was likely to be in the last weeks of her life. The doctor said using the Supportive Care Pathway would help to coordinate Mrs R’s care. They recorded that Ms A agreed to this approach. The hospital placed Mrs R on the Supportive Care Pathway following this meeting, on 29 March 2016.
  6. On 5 April 2016 Ms A raised concerns with nurses that Mrs R was drowsy and uncommunicative because she was on morphine. Both nurses recorded that staff had not given Mrs R any morphine. The medication chart shows doctors prescribed morphine on 4 April 2016 but there is no record staff ever gave it to Mrs R.
  7. A Consultant reviewed Mrs R on 6 April 2016 and discussed the case with a Respiratory Consultant. The Respiratory Consultant reviewed Mrs R the next day. They agreed that Mrs R’s prognosis was poor and treatment (beyond an oxygen mask) was unlikely to help. They agreed that using the Supportive Care Pathway was the right thing to do.

Analysis

  1. The records show the Council and Practice did act on Ms A’s request for rehabilitation for Mrs R. However, the relevant service decided any care it could provide was unlikely to help Mrs R.
  2. The records I have seen show that a range of professionals agreed that it was not safe for Mrs R to remain at home. They were concerned that her care package was not enough to cope with her needs and that this, in turn, could lead to harm and a loss of dignity. In view of these concerns the professionals decided to intervene to protect Mrs R from immediate harm while more appropriate long-term arrangements were made. Health and social care professionals are expected to do this. There is evidence to show that professionals worked together in Mrs R’s case, and this was good practice. There is no evidence to show the Practice lied about why it thought Mrs R needed to go into hospital.
  3. Neither the Practice nor the Council decided to adopt an ‘end of life’ approach for Mrs R. Medical staff in Sandwell Hospital made this decision. Their decision was based on Mrs R’s diagnoses, what they knew about her past health and her current health. This decision is supported by the evidence in Mrs R’s medical records and in line with established good practice. There is evidence (in the hospital, Council and Practice notes) to show the Consultant explained the reasons for their decision to Ms A. I have noted that Ms A found Mrs R to be drowsy and uncommunicative. This is not evidence, on its own, that she had been sedated as people can appear this way for a variety of reasons. While staff thought Mrs R was coming to the end of her life, there is nothing in the hospital records to suggest they thought she was dying or gave her medication to make her more comfortable. I have not found any evidence of fault here.

Complaint that Sandwell Trust kept Mrs R in Sandwell Hospital for too long

Events during Mrs R’s admission to Sandwell Hospital from 18 March to 8 April 2016

  1. A doctor reviewed Mrs R on 21 March 2016 and decided she did not have the mental capacity to decide where she should live. Therefore, it arranged a Best Interests meeting on 23 March 2016 to make this choice for her. The professionals decided that Mrs R should not go home as she would not be safe there. They said Mrs R needed to go to a care home that could provide 24 hour care.
  2. In the following days Sandwell Hospital noted a safeguarding referral had been made about whether Mrs R was safe at home. Members of staff told Ms A they could let Mrs R go home until this was resolved.
  3. On 31 March 2016 a Safeguarding Nurse, Safeguarding Social Worker and a Complex Discharge Nurse spoke to Mrs R. They noted she wanted to go home. However, they said they were not convinced she understood the risks involved as she could not say what the risks were, or explain how she had weighed them up. Therefore, they continued to feel Mrs R did not have the capacity to decide where she should live. Staff also still felt it would be unsafe for Mrs R to leave hospital without 24 hour care. Someone from Psychiatric Liaison saw Mrs R the next day, with a Punjabi interpreter. They agreed that Mrs R lacked insight into her current care needs and best interests.
  4. A doctor said Mrs R was as medically fit as she was going to get, on 5 April 2016. They said she could leave hospital once the practicalities of this had been worked out. On the same day, a Complex Discharge Nurse and Safeguarding Nurse met Ms A and said there was a place available at a local nursing home. They recorded that Ms A was keen for Mrs R to go there from hospital, with a view to returning home at a later date. Mrs R left Sandwell Hospital and went to the nursing home on 8 April 2016.

Analysis

  1. The records show that a range of professionals all felt that:
  • Mrs R’s needs were too great for her to be safely cared for at home
  • Mrs R did not understand how ill she was, or how much support she needed, and did not understand how vulnerable she would be without 24 hour care.

The professionals recorded why they had reached the view that Mrs R lacked the capacity to decide where she should live, and did so on a number of occasions. This was in line with relevant guidance.

  1. There is evidence in the hospital and Council records that professionals were working together to make sure Mrs R would be safe after she left hospital. Overall, there is evidence to show the process of discharging Mrs R took time due to concerns about her safety. This was reasonable and I have found any evidence of fault.

Complaint that City Hospital put Mrs R on an end of life pathway

Decision about Mrs R’s treatment during her admission to City Hospital from 25 April to 7 May 2016

  1. Mrs R went to A&E at City Hospital on 25 April 2016, due to abdominal pain. Doctors noted that during Mrs R’s last admission to hospital she had been put on the Supportive Care Pathway. On 5 May 2016 doctors discussed Mrs R’s case and reviewed her old notes. They said there was no ‘concrete evidence’ that Mrs R had reached ‘end stage’ COPD. Therefore, they said they would not restart the Supportive Care Pathway. The following day a doctor spoke to Ms A and explained this decision to her.

Analysis

  1. There is evidence to show the medical team actively considered Mrs R’s health and treatment options. There is evidence to show they moved away from end of life care during this admission. This was a professional judgement, based on the information available to the medical staff at that time. There is evidence staff considered appropriate information and weighed it up before making their decision. This was in line with established good practice and I have not found evidence of fault.

Complain that Sandwell Trust kept Mrs R in City Hospital for too long

Events during Mrs R’s admission to City Hospital from 25 April to 7 May 2016

  1. On 26 April 2016 Ms A said she wanted to take Mrs R home, rather than back to the nursing home. She said she was unhappy with the care in the nursing home. A nurse noted that safeguarding concerns about Mrs R’s safety at home had not been resolved. In view of this, staff told Ms A should could not take Mrs R home.
  2. A doctor spoke to Mrs R in Punjabi on 29 April 2016. They concluded she could make her own choice about where she lived. The doctor also said Mrs R was medically fit enough to leave hospital. However, over the following days Sandwell Trust said the safeguarding concerns about Mrs R’s safety at home needed to be resolved first.
  3. On 3 May 2016 City Hospital found out the safeguarding case had been closed. Professionals said they thought it would be safer for Mrs R to go back to a care home. However, they noted that Mrs R wanted to go home. Professionals contacted a care agency and referred Mrs R to community services. City Hospital tried to send Mrs R home on 6 May 2016 but needed to rearrange this for the next day due to the need for a suitable stretcher. Mrs R went home on 7 May 2016, to be supported by a care agency.

Analysis

  1. As with the previous admission, this was a complex situation due to the ongoing safeguarding concerns about whether Mrs R would be safe at home. It was appropriate for professionals to prioritise the need to keep Mrs R safe and to explore the concerns professionals had. Overall, I have not found evidence of any undue delay in the discharge arrangements and I find no fault.

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Decision

  1. I have completed my investigation on the basis that there is no evidence of fault from any of the organisations.

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Parts of the complaint that I did not investigate

  1. Ms A complained an ambulance crew dropped Mrs R from a stretcher to the floor on the night 15/16 March 2016. Ms A raised this concern with an Associate Medical Director on 24 March 2016, while Mrs R was in Sandwell Hospital. Doctors examined Mrs R during this admission and did not find any physical injuries they had concerns about. Staff got in touch with the ambulance service and its crew gave a different account of events. The crew said they had not dropped the stretcher and said Ms A acted aggressively toward Mrs R.
  2. At the start of April 2016 a Council Safeguarding Social Worker went to see Ms A and Mrs R and spoke to them about this incident. The social worker also noted the crew’s version of events. Several days later the Council decided it could not prove what happened either way.
  3. A lot of time has now passed since Sandwell Trust and the Council made these timely enquiries. I did not investigate this issue as it is very unlikely I would be able to add anything to what professionals (who did not work for the ambulance company) found at the time, or resolve these differing versions of events.

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Investigator's decision on behalf of the Ombudsman

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