The Ombudsman's final decision:
Summary: The Ombudsmen found that NHS and social care organisations provided appropriate care to an elderly patient over several months in 2016. There is evidence of appropriate assessments and actions in line with relevant guidance.
- Mr D complains about the care provided to his mother, Mrs N, between June and October 2016. During this time Mrs N:
- Was an inpatient at Wythenshawe Hospital twice. Manchester University NHS Foundation Trust (Manchester Trust) is responsible for Wythenshawe Hospital.
- Received support at home from HG Care Services Ltd (HG Care). Stockport Metropolitan Borough Council (the Council) arranged, and is responsible for, this support.
- Was an inpatient at Stepping Hill Hospital twice. Stockport NHS Foundation Trust (Stockport Trust) is responsible for Stepping Hill Hospital.
- Was assessed by staff from a Mental Health Liaison Team. Pennine Care NHS Foundation Trust (Pennine Trust) is responsible for this team.
- Mr D complains:
- Wythenshawe Hospital failed to provide adequate post-operative care after an operation in May 2016.
- Wythenshawe Hospital and Stepping Hill Hospital inappropriately discharged Mrs N on a number of occasions. Mr D said Mrs N was not fit from a physical or mental health perspective to be at home.
- The Council and HG Care failed to provide appropriate support for Mrs N at home. Mr D said they failed to provide Mrs N with an adequate care plan, and failed to respond adequately to Mrs N’s needs.
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 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.
- 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 considered records from each of the organisations along with relevant legislation and guidance. I took advice from a Consultant Vascular Surgeon, a Consultant in General and Respiratory Medicine, and a Mental Health Nurse.
- I shared a confidential copy of my draft decision with Mr D and the organisations under investigation to explain my provisional findings. I invited their comments and considered those I received in response.
What I found
- In 2016 Mrs N lived alone without any formal support. At the end of May 2016 she had an operation at Wythenshawe Hospital. She stayed in hospital for ten nights and then went home. The Council arranged for a carer (not from HG Care) to visit Mrs N once a day when she went home.
- Mrs N was confused and forgetful after she returned home. She went back into Wythenshawe Hospital in early July 2016, after 21 nights at home.
- Wythenshawe Hospital found the wounds from her operation were infected. The hospital initially treated Mrs N with IV antibiotics and by regularly redressing the wound. Later in the month it operated again. This surgery was to remove the dead/infected tissue and wash the wound out. The hospital prescribed further antibiotics after this operation. It changed the types of antibiotic several times during Mrs N’s admission and then changed them from intravenous to oral.
- During this admission blood tests showed Mrs N’s sodium levels were low. The hospital treated this by stopping some medication and giving Mrs N intravenous fluids. Mrs N’s sodium levels returned to normal levels.
- Mrs N left hospital and returned home in August, after 39 nights in hospital. She still had a prescription for oral antibiotics and the Council arranged for a carer (from HG Care) to visit once a day.
- There were concerns that Mrs N was not coping well at home and the Council agreed to increase her support to four visits a day. However, concerns remained and a GP arranged for Mrs N to go into Stepping Hill Hospital in early September 2016, after 26 nights at home. The hospital noted Mrs N was confused and hallucinating.
- The hospital felt Mrs N’s confusion could be related to low sodium levels. As in Wythenshawe Hospital, it treated this with fluids and by stopping some medication. The hospital also suspected Mrs N had a urinary tract infection (a UTI) and prescribed antibiotics for this. In addition, the hospital completed a CT scan of Mrs N’s brain which did not show any significant changes.
- In the middle of September 2016 doctors noted Mrs N’s sodium levels had improved, as had an infection marker, but she was still confused and paranoid. It referred her to the Mental Health Liaison Team. A nurse from the team saw Mrs N later in September. They planned to see Mrs N again in the community. Doctors noted this plan and were satisfied it was safe for Mrs N to leave hospital. Mrs N left hospital and returned home the next day, at the end of September 2016 (after 25 nights in hospital). She had an MRI scan before she left hospital. A doctor wrote to Mrs N’s GP about the outcome of this a couple of days later. As with the CT scan, it did not show anything significant.
- Mrs N continued to be confused and paranoid. After seven nights at home Mrs N went back to Stepping Hospital due to her increased paranoia and confusion. The hospital admitted her. It found she had a UTI and felt this was the probable cause of her confusion. It treated this with antibiotics.
- A couple of days later the hospital referred Mrs N back to the Mental Health Liaison Team. A member of the team saw Mrs N two days later. The team discussed the case the next day at a multi-disciplinary meeting. The team agreed Mrs N was probably suffering from delirium and gave the hospital some advice on treatment. It suggested treating Mrs N’s physical problems and to prescribe an anti-psychotic medication.
- Mrs N remained in hospital. Several days later the hospital noted Mrs N’s paranoid symptoms remained despite her blood results getting back to normal. After 15 nights in hospital it transferred Mrs N to a step‑down ward for people suffering from delirium, dementia and depression. She went to this ward to allow time for the symptoms of delirium to resolve in a supportive environment, and for support with discharge planning at the appropriate time.
- In total, from the end of May 2016 to the move to the step-down ward in late October 2016, Mrs N spent 89 nights in hospital (49 in Wythenshawe and 40 in Stepping Hill) and 54 nights at home. Records show that from December 2015 to late July 2016 Mrs N’s weight was quite steady and remained around 75kg. It then began to fall steadily and by the time Mrs N went into the step‑down ward it was 57.5kg.
Complaint (a): Manchester Trust failed to provide adequate post-operative care at Wythenshawe Hospital after an operation in May 2016
- Mrs N had surgery at the end of May 2016. In the hours after the operation Mrs N was drowsy, shaky and had a slow breathing rate. Medics felt this was probably a result of the drugs used during the operation. Mrs N was given fluids and doctors asked the nurses to record her observations every 30 minutes. In the evening doctors noted Mrs N was much improved, awake and alert. Mrs N’s observations continued to be within normal ranges by the following morning and doctors were satisfied she was stable. I find no fault in the way Manchester Trust managed Mrs N’s care during this time.
- In the early hours of 2 June Mrs N alerted staff to the fact that she was bleeding from the wound on her right groin. A nurse went to her. They put pressure on the bleeding, cleaned the area and put a pressure dressing on it. The nurse also alerted doctors. Several doctors came to review Mrs N shortly afterwards. They recorded that there was no more bleeding. The doctors examined Mrs N and noted a haematoma (a collection of blood) below the right groin. They also noted that Mrs N’s haemoglobin (a chemical in the red blood cells that carries oxygen around the body) was low. The doctors asked the nursing staff to monitor Mrs N every 15 minutes and Mrs N had a blood transfusion of three units of blood.
- The following morning doctors noted the haematoma had not grown and there were no concerns about Mrs N’s observations. The doctor prescribed a five day course of antibiotics and asked for physiotherapists to see Mrs N. Later that day a doctor noted that a blood test showed Mrs N’s haemoglobin level had improved after the blood transfusion.
- Nurses and doctors continued to monitor and review Mrs N over the following days. Her observations remained stable and within normal ranges and there were no concerns about her wellbeing. Overall, the clinical response to the bleeding and haematoma was appropriate and I find no fault.
- Mr D believes there is a direct link between these events and the increasing confusion, paranoia and hallucinations Mrs N had over the following months.
- As noted above, the CT and MRI brain scans Mrs N underwent did not show any significant results which would explain her symptoms. Staff from Manchester Trust, Stockport Trust and Pennine Trust struggled to find a clear explanation for Mrs N’s symptoms. In October 2016 the Mental Health Liaison Team said it felt they were most likely to be evidence of delirium. This working diagnosis was made following appropriate assessments and was consistent with Mrs N’s presentation.
- Delirium is a common syndrome, particularly in people who have surgery. The symptoms start suddenly and can include: being more confused than normal; hallucinations; paranoid beliefs; becoming disorientated; and, changes in behaviour.
- Overall, there is no persuasive evidence to show a link between Mrs N’s care after her operation and the mental health symptoms she showed in the following months.
Complaint (b): Wythenshawe Hospital and Stepping Hill Hospital discharged Mrs N before she was fit from a physical and mental health perspective
Discharge from hospital
- 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. I’ll refer to this as the Discharge Guidance.
- 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 (Care Act 2014, Schedule 3; and, the Care and Support (Discharge of Hospital Patients) Regulations 2014)).
First admission to Wythenshawe Hospital
- Doctors first began planning for Mrs N to go home the day after her operation, before she had the episode of bleeding. After the bleeding and discovering Mrs N had low haemoglobin this plan changed. On 5 June the medical team noted a plan for Mrs N to go home once the Physiotherapy and Occupational Therapy (OT) teams were happy for her to do so.
- Physiotherapy reviewed Mrs N the next day and confirmed it did not need to see her again. Nursing and medical staff both noted the need to involve social services and arrange support at home before Mrs N could leave. Staff made the referral to social services the next day.
- On 10 June (a Friday) OT confirmed it did not need to see Mrs N again. A social worker discussed Mrs N’s needs with her and agreed to arrange some support. Staff told Mrs N the home support could not start until Monday. Mrs N said she did not want to stay in hospital over the weekend and said her family would support her while she waited for the Council-arranged support to start.
- I am satisfied there is evidence to show Manchester Trust took an appropriate multi-disciplinary approach to Mrs N’s care. It considered her acute medical needs and found there was no treatment that Mrs N needed that required her to stay in an acute, inpatient environment. Staff also considered Mrs N’s ability to walk and to manage her day-to-day needs. Again, it did not find anything that needed a continued stay in hospital. Therefore, I have not found any evidence of fault in the way Manchester Trust managed this move out of hospital.
Second admission to Wythenshawe Hospital
- Around a month into Mrs N’s second admission to Wythenshawe doctors reviewed her and felt it would be suitable for her to return home. By this time the Physiotherapy team had already completed its work with Mrs N. Staff referred Mrs N back to social services and they arranged support for when she got home.
- As with the first admission there is evidence of an appropriate multi-disciplinary approach. The medical staff kept Mrs N under regular review and monitored her symptoms. As with the first admission, there was nothing that required any ongoing inpatient treatment. The nursing staff also regularly reviewed Mrs N. Overall, I have not found evidence of fault in the way Manchester Trust planned Mrs N’s return home.
First admission to Stepping Hill Hospital
- Doctors first felt Mrs N was medically well enough to go home a week after she went into Stepping Hill. However, a couple of days later it changed this decision and noted the need to involve mental health colleagues first. Once someone from the Mental Health Liaison Team reviewed Mrs N (at the end of September 2016) medics confirmed again that they were happy for Mrs N to return home. Prior to this the Physiotherapy and OT teams had already completed their work with Mrs N, and the Council had agreed to arrange support for when she got home.
- As at Wythenshawe, there is evidence that Stockport Trust considered Mrs N’s needs in the round and involved professionals from a variety of disciplines. The medical team treated the physical problems they found and made referrals to help ensure Mrs N’s symptoms were investigated further. The Mental Health Liaison Team (from Pennine Trust) reviewed Mrs N while she was an inpatient. It arranged to see her again after she returned home as it did not find evidence she needed inpatient treatment. Therefore, I have found no evidence of fault in the way Stockport Trust reached its decision to discharge Mrs N.
Complaint (c): The Council and HG Care failed to provide appropriate support for Mrs N at home
- 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 (Care Act 2014, sections 9 and 10).
- There are standards for safety and quality care homes need to meet: The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. I will call these the Regulations. The Care Quality Commission (the CQC) has written guidance to help care homes meet these standards: Guidance for providers on meeting the regulations (March 2015). I will refer to them as the Fundamental Standards.
- Under the Regulations and Fundamental Standards care providers need to make sure:
- They provide people with appropriate care, personalised to their needs. This includes taking account of the person’s preferences, and ensuring care and treatment is only provided with their consent. As part of this, care providers need to make sure assessments are regularly reviewed (Regulation 9)
- People are treated with dignity and respect at all times. This involves ensuring the person has privacy, supporting their independence and respecting their wishes (Regulation 10)
- Staff must get a person’s consent before they provide any care or treatment. As part of this, staff should ensure the person has enough information to make an informed choice, including about risks (Regulation 11)
- People are kept safe from avoidable risk and harm, and from unsafe care and treatment. This includes assessing risk and making plans to manage it. Care homes also need to make sure staff are appropriately trained, and that equipment is suitable and available (Regulation 12)
- There is evidence to show that Social Workers visited Mrs N while she was an inpatient. They discussed her needs and identified areas where she would need help. The Social Worker proposed a proportionate package of care to meet those identified needs.
- HG Care also completed its own assessment of Mrs N once it began supporting her. There was a proportionate plan in place that noted the care to be provided to meet Mrs N’s identified needs.
- The records show that HG Care were proactive in contacting the Council to ask for an increase in Mrs N’s support. The Council responded to this request quickly and authorised the increase. This was appropriate. There is also evidence in the records of regular contact between HG Care, the Council and other professionals about Mrs N. This was in line with the requirements of the Fundamental Standards.
- Overall, I am satisfied there is evidence to show the Council continued to monitor Mrs N’s situation after it had found her to have a need for support. Further, there is evidence to show the Council made proportionate efforts to support Mrs N in the community. Therefore, I find no fault.
- I have completed my investigation on the basis there is no evidence of fault.
Investigator’s decision on behalf of the Ombudsmen
Investigator's decision on behalf of the Ombudsman