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Northern Lincolnshire & Goole NHS Foundation Trust (17 002 564b)

Category : Health > Hospital acute services

Decision : Not upheld

Decision date : 24 Jan 2018

The Ombudsman's final decision:

Summary: The evidence does not support the claim that there was fault over the decision to discharge Mr P to his own home in June 2016. Mr P died in bed, not in a wheelchair in a corridor on NAViGO’s Ward. NAViGO was not at fault for preparing Mr P for a colonoscopy the Trust had identified him as needing.

The complaint

  1. The complainant, whom I shall refer to as Mrs M, complains about:
    • flaws in the decision to discharge her ex-husband, Mr P, from a ward run by NAViGO Health & Social Care CIC (NAViGO) on 3 June 2016, including the mental capacity assessment and the decision that he could be safely discharged to his own home;
    • the care and treatment of Mr P when he returned to the ward, including giving him medication in preparation for a colonoscopy when he was not well enough for the procedure, the care he received in the last days of his life and that he died in a wheelchair in a corridor.

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The Ombudsmen’s role and powers

  1. 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))
  2. 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.
  3. 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.

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How I considered this complaint

  1. In reaching my view I have:
    • discussed the complaint with Mrs M’s Advocate and considered the information she sent to us;
    • considered the documents provided by Northern Lincolnshire & Goole NHS Foundation Trust (the Trust), NAViGO Health & Social Care CIC (NAViGO) and North East Lincolnshire Council (the Council) in response to our enquiries; and
    • taken account of the comments received on a draft of this statement.

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What I found

  1. Mr P went into hospital on 3 May 2016. Before going into hospital Mrs M and her partner helped care for him in his home.
  2. On 11 May Social Worker X (employed by the Council) did a mental capacity assessment to decide whether Mr P had the capacity to decide where he should be discharged to. Social Worker X noted Mr P was generally unwell and this led to “notable states of confusion”. Social Worker X decided Mr P had “an impairment, or disturbance in the functioning of [his] mind or brain which could affect [his] ability to make this decision”. Social Worker X decided Mr P did not have the capacity to decide his discharge destination. This was because the answers to fours questions about his ability to understand, retain, weigh up and communicate information about the decision were all “no”. Under the Mental Capacity Act 2005 only one answer had to be “no” for Mr P to lack the capacity to make the decision. Social Worker X decided Mr P was unlikely to regain the capacity to make the decision. Mr P’s family, including Mrs M, were present for the capacity assessment.
  3. Mrs M told Social Worker X Mr P should go to a care home when he left hospital. Mrs M said they had identified one.
  4. Mr P was transferred to NAViGO’s Home from Home Ward (the Ward) at the hospital on 13 May “for further assessment prior to discharge”.
  5. On 18 May Social Worker Y (employed by NAViGO) did a mental capacity assessment with Mr P. Social Worker Y found Mr P had the capacity to decide about his future care. This was because, despite being diagnosed with a mild cognitive impairment in 2015, he could understand, retain, weigh up and communicate information about the decision.
  6. On 24 May Social Worker Y and other staff from the Ward had a meeting with Mr P’s family, including Mrs M and her partner. Social Worker Y explained about the mental capacity assessment. She said Mr P wanted to return home when he left the Ward. She explained that even if this was an “unwise” decision, Mr P had the capacity to make it.
  7. On 31 May Mrs M and her partner had a meeting with Social Worker Y, the Mental Health & Dementia Lead, and the Clinical Team Lead. Social Worker Y said Mr P wanted to go home and he had the capacity to make that decision for himself. Mrs M said Mr P had said he wanted to go to residential care. Social Worker Y accepted that was the case but pointed out that on several other occasions he had said he wanted to go home. She said Mr P had not agreed to go to the care home when it came assess him.
  8. On 1 June Mr P agreed a care plan for his return home, with help from NAViGO’s Home from Home Service and a private care provider. The care plan says he would receive four calls a day:
    • morning – to help get up, wash, dress, use the toilet, have breakfast, take medication and put the washing machine on;
    • lunchtime – to prepare a ready meal, encourage fluids, help to the toilet and put the washing out to dry;
    • tea time – to prepare a snack, encourage fluids and help to the toilet;
    • evening – to help into nightwear and continence pad, encourage fluid, prompt medication.
  9. Mr P was discharged home in the evening of 1 June. The records of the Ward’s visits to Mr P at home show he struggled to cope and continued to have a poor diet, although he agreed to take some food supplement drinks.
  10. Mr P was readmitted to the Ward on 4 June. This followed concerns raised by neighbours and Mrs M about him leaving his home in a confused state at night. NAViGO’s initial assessment says Mr P was disoriented to time but understood the reason for readmission to the Ward.
  11. On 17 June Mr P was found not to have the capacity to make decision about his future care.
  12. NAViGO’s records show Mr P was due to have a colonoscopy on 20 June. The Trust had arranged this when Mr P was on another ward at the hospital.
  13. According to NAViGO’s records for 20 June Mr P said he was feeling OK. He was not in any pain; his abdominal pains had improved. He was largely independent when mobilising. However, Mr P had twice pulled out a cannula for giving fluids. The records say the colonoscopy was not performed as it was organised on the basis of a CT scan but a previous CT scan only showed pancolonic diverticulosis.
  14. NAViGO’s records of the Doctors’ visits on 21 June say Mr P was becoming frailer. He appeared comfortable but was “declining generally in health”; his eating and drinking had reduced. The plan was to discharge Mr P following a best interests meeting. It says he was for “Ward level care” and not for readmission to hospital.
  15. NAViGO’s records for 29 June say Mrs M suggested Mr P should move to one of the Trust’s wards at the hospital. Mrs M denies saying this. According to NAViGO, it told Mrs M the Doctors had decided to keep Mr P on its Ward as he was “for conservative management and not escalation to any other ward”. Mr P had bloods taken at 20.40 when he was in bed. He asked to have coffee in the communal area and was taken there in a wheelchair. He became unresponsive (had a pulse but minimal respirations) and was taken back to bed where he died at 21.01.
  16. Mrs M complained to the Trust on 25 July. The Trust passed Mrs M’s complaint on to NAViGO.
  17. NAViGO responded to Mrs M’s complaint on 20 October. It apologised that its care for Mr P fell below the expected standards. It said:
    • Mr P had the capacity to decide to return home on 1 June;
    • it would have been preferable for Mr P to return home the following morning so he could have received care throughout the day;
    • the decision to discharge Mr P was made by a team involving Doctors from the Trust as well as NAViGO’s Consultant Psychiatrist;
    • the ward had supported Mr P to attend the appointment for a colonoscopy arranged by colleagues in the Trust;
    • it apologised if the medical care and advice about Mr P had been confusing.
  18. Mrs M complained again in November. NAViGO sent its final response on 5 December. It told her the Home from Home service had now closed.

Were there faults causing injustice?

  1. The Mental Capacity Act 2005 and the associated Statutory Guidance, explain how to assess capacity and when decisions can be made in someone’s best interests. The evidence shows the decision to let Mr P return home on 1 June was in line with the Act and the Statutory Guidance. There was no fault by the bodies involved in that decision. Although Mr P lacked the capacity to decide his discharge destination on 11 May, by 18 May he had recovered sufficient capacity to make that decision. The fact that he had not been expected to recover capacity on 11 May, does not mean there was any fault with the 18 May assessment. The Statutory Guidance makes it clear that capacity needs to be kept under review and that wherever possible people need to be helped to make their own decisions. It also says people with capacity are entitled to make decisions which others consider to be “unwise”.
  2. NAViGO was not at fault for preparing Mr P for a colonoscopy on 20 June which the Trust had identified him as needing. Mr P was on the Ward for the purpose of further assessment. That the colonoscopy did not go ahead does not mean NAViGO was wrong to prepare him for it.
  3. The evidence does not support the claim that Mr P died in a corridor in a wheelchair. The records show Mr P died in bed on the Ward.
  4. NAViGO has accepted some fault over the care Mr P received (e.g. sending him home on 1 June, rather than 2 June). It has also accepted some fault over the way its staff communicated with Mrs M. It has apologised for these failings. There is no further action it needs to take.

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  1. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman

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