The Ombudsman's final decision:
Summary: The Ombudsmen find fault in the way a Trust discharged a patient from hospital several times. The Ombudsmen recommend an apology for the distress the failings caused.
- Mr W was treated in Darent Valley Hospital (managed by Dartford and Gravesham Trust (the Trust)) several times between June and September 2016. Each time Mr W left hospital he was unable to return to his own home and went to a care home, paid for privately. Mr W’s son, Mr D, said he placed his trust in, and accepted the views of, the professionals looking after Mr W during these times. Mr D said the family did not know what questions to ask, or what care or funding options were available.
- Mr D complains that:
- Professionals did not properly assess Mr W before he left hospital on each occasion. Mr D said, as a result, there was a lack of care planning and no assessment of how Mr W’s care would be funded. Further, Mr D said he had to chase up Kent County Council (the Council) to assess Mr W.
- Professionals did not tell them about intermediate care. Mr D said the time Mr W spent in the care home did not exceed six weeks at any point.
- The Council failed to contact him as promised. Mr D said this caused an avoidable delay in the assessment process.
- Mr D said these events had a significant financial impact as Mr W paid around £1,300 per week in care home fees. Mr D said he felt pressured to place Mr W in the care home, and said these events caused him and his father great distress.
- As a result of his complaint Mr D would like the care home fees to be reimbursed. He would also like the Trust and Council to acknowledge the distress caused to the family and to apologise.
The Ombudsmen’s role and powers
- 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).
- 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).
- 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).
How I considered this complaint
- I read the correspondence Mr D sent to the Ombudsmen and spoke to him on the telephone. I wrote to the Trust and the Council 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.
- I shared a confidential copy of my draft decision with Mr D, the Trust and the Council to explain my provisional findings. I invited comments and considered those I received.
What I found
- 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. 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. I’ll refer to this as the Discharge Guidance.
- This has been added to by a guideline from the National Institute for Health and Social Care Excellence (NICE) in 2015: Transition between inpatient hospital settings and community or care home settings for adults with social care needs. I’ll refer to this as the Transition Guidance. This echoes the Discharge Guidance in recommending close working and regular contact between health and social care staff, to make sure moves from hospital are well coordinated and everything is in place (Section 1.1.4, Transition Guidance). It also repeats the Discharge Guidance that assessing a person’s needs should start straight away, and should address a range of factors including the need for assessments of eligibility for health or social care funding (Section 1.5.13, Transition Guidance). This should result in a plan that includes any arrangements for ongoing health and social care (Sections 1.5.15 to 1.5.20, Transition Guidance).
The need to advise social services of patients who may need support
- As part of the discharge process hospitals need to think about whether it might be unsafe to discharge a patient without measures in place to meet their care and support needs. If it thinks it might be unsafe it must tell the relevant council of that patient, and it should talk to the patient about this. The hospital then needs to consult with the council before deciding what it will do to make sure discharge is safe (Schedule 3, Care Act 2014; and The Care and Support (Discharge of Hospital Patients) Regulations 2014)).
- Involving the patient and their family or carers is a fundamental part of the discharge process (Chapter 3, Discharge Guidance; and Section 1.1, Transition Guidance; and Annex G, paragraph 54, Care and Support Statutory Guidance).
The need to consider eligibility for Continuing Healthcare first
- Before notifying social services the hospital should consider whether the patient might qualify for Continuing Healthcare (CHC) funding (Paragraph 62 of the National framework for NHS continuing healthcare and NHS-funded nursing care). This is because councils cannot lawfully provide services that are the legal responsibility of the NHS (Section 15.29, Care and Support Statutory Guidance).
The Trust’s discharge policy
- The Trust has its own discharge policy. This includes good practice principles that reflect the national guidance. This includes ensuring that ‘assessment for, and delivery of, continuing health and social care is organised so that individuals understand the continuum of health and social care services and receive advice and information to enable them to make informed decisions about their future care’.
- A section on ward multidisciplinary meetings notes that ‘Patients requiring a complex package of social care, or re-accommodating in a residential/nursing home or a period of rehabilitation must be [assessed] by nursing staff in conjunction with the [multidisciplinary meeting]. This discussion should be documented in the patient’s healthcare record and must be discussed with the patient and/or next of kin’.
- It goes on to note that ‘Based on the assessment, if the patient has predominantly health needs, the [multidisciplinary meeting] led by the nursing staff should consider the patient for an application for NHS continuing healthcare’.
- And, ‘If the individual is not assessed as eligible for NHS continuing healthcare Adult Social Care will assess and provide support with an emphasis on the patient’s care transferring to their home. Patients are entitled to an assessment regardless of their ability to pay although some who are able to fund their own care may prefer to make their own arrangements’.
Council assessments and charging
- Councils must carry out an assessment for any adult when it appears they might need care and support. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve (Sections 9 and 10, Care Act 2014).
- Councils can charge for care and support services they provide or arrange (Section 14, Care Act 2014; and Section 8.2, Care and Support Statutory Guidance). Councils must assess a person’s finances to decide what contribution they should make to a personal budget for care (Section 17, Care Act 2014).
- If a person is a permanent resident in a care home and has more than the capital limit (currently £23,250) they are not eligible for financial support from the council and must pay the full cost of their care (Section 12(1), The Care and Support (Charging and Assessment of Resources) Regulations 2014; and Sections 8.12 and 8.13, Care and Support Statutory Guidance).
- Where a person is a short-term resident in a care home (someone provided with accommodation for eight weeks or less) councils can choose to charge them for care based on the rules for non-residential care (Section 8.34, Care and Support Statutory Guidance).
- Intermediate care can be provided to people after they have left hospital or when they are at risk of being sent to hospital. This type of care is meant to be for a limited period to help the person regain (or keep) the ability to live independently (Section 2.14, Care and Support Statutory Guidance). Councils cannot charge for this in the first six weeks (Section 3, The Care and Support (Charging and Assessment of Resources) Regulations 2014; and Section 2.61, Care and Support Statutory Guidance).
- The local intermediate care service notes that it provides ‘short-term health and social care support and/or rehabilitation to people in the community. We aim to enable patients, where possible, to remain in the community rather than be admitted to hospital or long-term care’ (https://www.kentcht.nhs.uk/service/intermediate-care/).
Timeline of events
Situation prior to April 2016
- Mr W lived alone in a bungalow. His wife lived in a nearby care home (the Care Home). Mr W had several long-term health conditions including atrial fibrillation (an irregular heartbeat), high blood pressure, raised cholesterol, recurrent urinary tract infections (UTIs) and had a long-term catheter.
Admission to hospital in April 2016
- In early April 2016 Mr W fell at home and hit his head. An ambulance took him to hospital and he was found to have a subdural haematoma (a collection of blood between the brain and skull). The hospital admitted Mr W and decided to treat him conservatively, without surgery. During Mr W’s admission the hospital also treated him for a UTI and found him to be MRSA positive (an infection caused by a type of bacteria that is resistant to several widely used antibiotics).
- Staff noted Mr W was confused. They also noted Mr W could not move about on his own although he was normally able to do so, and he needed staff to help him wash and dress. Staff from Physiotherapy and Occupational Therapy (OT) reviewed Mr W. At the end of April 2016 they referred him to the Sapphire Unit – a rehabilitation unit at a community hospital. Mr W transferred there at the end of April (25 days after he entered hospital). The stated goals of the placement were for Mr W:
- to be independent with all transfers in one week;
- to be able to shower independently (using a seat) and dress independently in two weeks; and,
- to be able to independently mobilise in two weeks.
Admission to hospital in May 2016
- Mr W returned to hospital five days later. He was admitted due to confusion and poor mobility, and this was found to be due to sepsis. Early in the admission staff noted Mr W was at risk of falling and moved him from a side room to a bay to increase the amount of supervision.
- In the middle of May 2016 doctors felt Mr W was medically stable and said the aim should be get transfer him back to a rehabilitation bed. Physiotherapy and OT discussed this the next day and agreed with the plan, as did Mr W. The hospital sent a referral to the Sapphire Unit but Mr W had a fall later the same day. Following the fall doctors no longer considered Mr W to be medically stable enough to leave hospital.
- Around a week later a member of staff spoke to one of Mr W’s relatives about discharge planning. The family member noted they were keen for Mr W to return to the Sapphire Unit. The member of staff said this might not be possible because of Mr W’s risk of falling and suggested the family think about other options.
- The following day Physiotherapy reviewed Mr W with a family member present. The family member said the family had collectively decided it would be best for Mr W to go to the same care home as his wife for a period of respite. The Physiotherapist noted that Mr W agreed with this plan, and all understood there ‘may not be much potential to reach previous level of mobility’. They also noted that the family were aware a period of respite at the Care Home would be self‑funded.
- In early June 2016 the hospital sent a referral to the Sapphire Unit, requesting a further period of rehabilitation. However, there was uncertainty about whether Mr W would be suitable.
- Ward staff also told the hospital social services team of Mr W. When the social services team asked about Mr W a couple of days later they were told he was not medically fit for assessment. The social services team asked the ward to contact them again once Mr W was ready.
- A nurse spoke to a member of Mr W’s family on 10 June 2016 and noted the family had arranged for the Care Home to assess Mr W, with a view to going in for temporary/respite care. Staff discussed this plan with Mr W after the weekend and he agreed with it. The Care Home came to assess Mr W the same day.
- In the middle of June 2016 (42 days after he had been admitted) Mr W left the hospital and went into the Care Home. The family arranged this privately and arranged to pay on a week-by-week basis, with the hope that Mr W would improve and be able to return home. On the day Mr W moved a hospital nurse spoke to a member of the family about CHC funding and suggested they consider an assessment for this.
Admission to hospital in July 2016
- Mr W returned to hospital 24 days later. The hospital determined he was suffering from sepsis with septic shock and multiorgan failure.
- The hospital admitted and treated Mr W. Physiotherapy, OT and Speech and Language Therapy (SALT) also regularly reviewed Mr W during his admission.
- In early August 2016 a nurse spoke to the Care Home which said it was happy to have Mr W back. They then spoke to members of Mr W’s family who said they were happy for Mr W to go back to the Care Home. Mr W returned to the Care Home the same day (26 days after he entered hospital).
Admission to hospital in August 2016
- Mr W went back to hospital five days later. He had a fast heart rate and there were concerns he was not taking enough fluids.
- Physiotherapy, OT and SALT reviewed Mr W regularly. The Care Home came to assess Mr W on the first day of September 2016. Mr W left hospital and returned to the Care Home the next day (24 days after he had gone into hospital).
Contact with the Council in August 2016
- On 22 August 2016 a CHC Assessor contacted the Council and noted they had completed a Checklist which recommended a full assessment. The assessor asked the Council to take part in the assessment process.
- A CHC assessment took place on 19 September 2016, while Mr W was in the Care Home. It recommended Mr W was not eligible. The Council also completed a social care assessment at the same time. It was not able to complete a financial assessment as not all the necessary information was to hand.
Admission to hospital in October 2016
- Mr W went back in to hospital in early October 2016 (37 days after he left). He was less responsive then normal and had a high respiratory rate and fast heart rate. Mr W was again felt to be suffering from sepsis. It was also noted that he had been diagnosed with Parkinson’s disease in the community.
Contact with the Council in October 2016
- Mr D spoke to a Council case manager shortly after Mr W returned to hospital. Mr D raised concerns about the family having to pay for Mr W’s care. The case manager told Mr D they would call back.
- Mr W continued to deteriorate and sadly died later in October 2016.
Timeline of complaints
- Mr D complained to the Council on 16 October 2016. The Council acknowledged the complaint and sent it to the Trust. It told Mr D it and the Trust would send separate responses.
- The Council replied to Mr W’s complaint on 17 November 2016. It said the hospital did not refer Mr W to social services. The Council said because Mr W had not been known to them in June it had not carried out an assessment to determine his needs and eligibility for support. The Council said, as such, it would not reimburse the care home costs. However, the Council acknowledged the social worker did not call Mr D back on 12 October 2016 and apologised.
- Mr D chased the Council for a response to the rest of his complaint in December 2016 and January 2017. The Council provided him with contact details to get in touch with the Trust directly.
- The Trust wrote to Mr D on 2 May 2017. The Trust said its staff assumed a CHC assessment had already been carried out in the community. The Trust apologised. It said they made this assumption as Mr W came to hospital from a care home, and because the home environment is the best place to complete a CHC assessment.
- The Trust said it would use this complaint to improve its discharge processes. It said it would make sure staff made enquiries about: whether there has been a previous assessment; and, if the patient has been admitted from a permanent or respite placement.
- Mr D remained dissatisfied and wrote back to the Trust. The Trust sent its final response on 17 August 2017. It did not change its earlier conclusions.
- The Trust had a responsibility to consider Mr W’s ongoing needs before it discharged him from hospital. As part of this, it had a duty to first consider whether Mr W might qualify for CHC and, if not, to send assessment and discharge notices to the Council.
- The Trust did not consider Mr D’s eligibility for CHC. It said it assumed this had been considered in the community. However, this does not tie in with the notes of a telephone call from a nurse to the family when Mr W left hospital in June 2016. The nurse suggested the family ask for a CHC assessment.
- Aside from this, the Trust should have checked the situation rather than make assumptions. Further, even if Mr D’s eligibility had previously been considered, there should have been consideration of whether his overall needs had changed since his admission to hospital, and whether that might lead to a different decision. There is evidence that Mr D spoke to a doctor about CHC after Mr W went into hospital in August 2016, and the doctor planned to speak to colleagues about it. A Checklist was then completed in late August 2016.
- Overall, the failure to properly consider CHC before Mr W left hospital (in June and early August) is fault on the part of the Trust.
- Mr D’s eligibility for CHC was later assessed in mid‑September 2016. This found he was not eligible. From the evidence I have seen his needs were similar in September to how they had been in June and August. Therefore, on the balance of probabilities, Mr D did not miss out on CHC funding because of this fault.
- However, aside from not properly considering CHC, the Trust also failed to involve the Council. The Trust had a duty to send assessment and discharge notifications to the Council, to make sure it was aware of Mr W and completed the necessary assessments. The Trust did refer Mr W to social care in early June. However, it was told to re‑refer him once he was ready for an assessment but this never happened. This failure to send appropriate notifications to the Council (in June, August and September) was fault. As a result, the Council could not arrange to assess Mr W’s needs and eligibility for support.
- In addition, the Trust did not give Mr W or his family enough information. In May 2016 (when it first seemed the Sapphire Unit might not be able to take Mr W back) staff advised the family to consider other options. However, there is no evidence they offered any information about different options, including speaking to the Council about a social care assessment and asking for its help in finding a placement. There is evidence to show a member of staff told the family a stay in the Care Home would be self-funded, but this was before a CHC, social care or financial assessment had been completed.
- The Discharge Guidance notes that staff should ‘Always consider rehabilitation and enablement as the first options’ (Step 7, paragraph 12). There is evidence to show the Trust referred Mr W back to the Sapphire Unit for rehabilitation. There is also evidence to show regular involvement from physiotherapy and occupational therapy. The records show that professionals did not consider it would be safe for Mr W to return home because of the level of support he needed. Therefore, there is enough evidence to show staff appropriately considered Mr W’s potential for rehabilitation and, by extension, his eligibility for intermediate care services. As such, I have not found that Mr W missed out on free intermediate care during this period.
- Had the Council been correctly told of Mr W before he left hospital it would have needed to assess his eligibility for support. It would also have needed to complete a financial assessment to check if he was eligible for financial support.
- The Council learned of the need to assess Mr W in late August 2016 and began assessing Mr W’s needs in late September 2016. It was unable to complete a financial assessment as the relevant information was not to hand. A member of staff spoke to Mr D at the end of the same week and noted the need for a financial assessment. It next spoke to Mr D over two weeks later. It did not get all the information it needed but it did not call Mr D back. This was fault.
- The Council said it would like to offer a further apology for the distress caused by not contacting Mr D at the agreed time to make an appointment. It said that, because it had not called, it had still not completed a financial assessment for Mr W. This apology was an appropriate remedy.
- The Council said it would be willing to work with Mr D to retrospectively look at Mr W’s eligibility for financial support when he was in the Care Home. The Council said this would include looking at the date when Mr W became eligible and the level of financial support. It said this process would involve a retrospective financial assessment.
- The Council has contacted Mr D about this process but Mr D does not wish to pursue the financial assessment. This is because, from the information immediately to hand, it seems highly probable Mr W’s financial situation meant he would have been liable for the cost of his own care.
- Therefore, while Mr W’s financial circumstances remain unassessed, on the balance of probabilities there has not been any financial impact because of the Trust’s faults.
- In addition to missing out on the key assessments at the time, Mr W and his family also missed out on more complete information. Had the Trust referred Mr W to the Council at an appropriate time before he left hospital the family is likely to have received more information. This is likely to have included information about possible care homes along with information about the limits of Council funding and other considerations, such as top‑up fees. This may have had an impact on the family’s choice of care home. However, Mr W’s wife lived in the chosen care home. Further, notes from a nurse about a conversation with a family member on 10 June 2016 suggest the family had given the move to the Care Home careful thought. Therefore, having weighed the evidence in the balance, it does not seem likely that any more information would have changed the decision to choose this care home.
- Within one month of the date of the final decision the Trust should write to Mr D to acknowledge it did not manage Mr W’s discharges from hospital appropriately in June, August and September 2016. Specifically, it should acknowledge it did not properly consider CHC, did not send the necessary referrals to the Council and did not ensure the family were given enough information. The Trust should also apologise for the stress and inconvenience this caused Mr D and the family.
- I have closed this investigation on the basis there was fault on the part of both the Trust and Council. This led to an injustice. The Council has already provided an appropriate remedy for its fault and I have made recommendations to put the impact of the Trust’s fault right.
Investigator’s decision on behalf of the Ombudsmen
Investigator's decision on behalf of the Ombudsman