Shrewsbury and Telford Hospitals NHS Trust (17 017 939a)

Category : Health > Hospital acute services

Decision : Upheld

Decision date : 11 Jan 2019

The Ombudsman's final decision:

Summary: A man complained that his mother was discharged from hospital unsafely by an NHS Trust and that the Council did not arrange a care package for her. He said as a result, his mother became very distressed and they had to arrange an urgent respite placement for her. The Ombudsmen find that there were failures with the NHS Trust’s discharge planning but the Council did arrange a care package. The Trust has agreed to apologise and explain how it will avoid similar issues in future.

The complaint

  1. Mr P complained about the care provided to his mother Mrs D by Shropshire Council (the Council) and The Shrewsbury and Telford Hospital NHS Trust (the Trust). He said:
      1. Mrs D’s discharge from hospital in October 2017 was unsafe, because no care package was in place and no family members were available to support her. He said information provided by the family was disregarded, and a pre-discharge case conference was promised but did not take place.
      2. As a result, Mrs D was discharged home with no support, and became very distressed. The family had to had to take steps to arrange an urgent respite placement.
      3. Mrs D should have got six weeks free care under the reablement scheme, so the Council should reimburse them for the first six weeks of her care.
  2. Mr P would like the failings in his mother’s care to be acknowledged, and for both organisations to make changes to prevent this happening again to others.

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What I have investigated

  1. I have investigated parts a and b of the complaint. At the end of this statement I have explained why I did not investigate part c.

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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)). If it has, they may suggest a remedy. 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.
  2. 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 for both Ombudsmen. (Local Government Act 1974, section 33ZA, and Health Service Commissioners Act 1993, section 18ZA)
  3. The Ombudsmen may investigate complaints made on behalf of someone else if they have given their consent. The Ombudsmen may also investigate a complaint on behalf of someone who cannot authorise someone to act for them, if the Ombudsmen consider them to be a suitable representative. (Health Service Commissioners Act 1993, section 9(3) and Local Government Act 1974, section 26A(2)) (Local Government Act 1974, section 26A(1))
  4. The Ombudsmen cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
  5. 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)

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How I considered this complaint

  1. I considered information provided by the parties to the complaint, including relevant health and social care records. I took account of relevant policy, law and guidance. I took clinical advice from a specialist nurse with expertise in caring for older people within an inter-disciplinary team.
  2. I shared a draft of this decision with the parties to the complaint and considered their comments.

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What I found

  1. Department of Health guidance: Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate care (2010), (the ‘Ready to go guidance’) is the core guidance around hospital discharge. It contains key steps for staff to follow during discharge planning.
  2. The Ready to Go guidance says carers should be involved from the beginning of discharge planning. It also says staff should check information they are given by patients about “their relative’s willingness and ability to care”, because sometimes patients say a relative will care for them when the relative cannot. Therefore, staff should check with the person concerned. Discharging someone requires a decision with the patient and their family about what needs to happen so that the discharge is safe.
  3. Department of Health guidance: Achieving timely ‘simple’ discharge from hospital: A toolkit for the multi-disciplinary team (2004) says a patient is medically stable when test results etc. are normal for the patient. A patient is fit for discharge when medical, social, functional and psychological factors have been taken into account, following a multi-disciplinary assessment when needed.

What happened

  1. Mrs D, aged 90 at the time, was admitted to hospital on 15 September 2017 because she was unwell. Before this, she lived alone without any social care. She could care for herself, and walk with a stick.
  2. A physiotherapist noted on 20 September that Mrs D’s daughter, Ms F, lived with her but was currently away. Mrs D said she did not think she would cope at home without her daughter. The therapist noted that they would need to contact Ms F to check when she was home and whether she was happy with the “set up” at home. Mrs D fell that day when she was moving from her chair to her bed.
  3. Therapy staff recorded on 21 September that Mrs D had some equipment at home to help with her independence. This included a pendant alarm, an adjustable bed, a riser recliner chair to help her sit down and get up, a commode which she kept in the garage and did not use, and rails to help her use the shower. Mrs D was washing and dressing herself independently, but felt very tired. Mrs D agreed to an occupational therapist contacting her son about Mrs D’s concerns about going home.
  4. An occupational therapist noted on 3 October that Mrs D was concerned about how she would cope at home. The therapist advised Mrs D she could either go home with a social care package, or move to a rehabilitation placement. Mrs D said she did not want a care package. The therapist noted that Mrs D could move around safely, but her confidence was low. She would wait for a rehabilitation placement to increase her confidence.
  5. Hospital records of 4 October say Mrs D was medically ready to leave hospital. By that time, she could walk 7 metres with a walking stick and assistance from one person. They still aimed for a rehabilitation placement. This was because Mrs D was not as mobile as before admission, her confidence was lowered and she did not want a care package at home.
  6. Later that day, the ward sister told the therapist that Mrs D could not go to a rehabilitation placement because her mobility was too good, so she would not be accepted. The therapist spoke with Mrs D about this, who agreed to go home with a care package. She said twice daily would be enough because her daughter lived with her and would be able to help her with meals in the evening. Mrs D also said her head felt “all over the place”.
  7. The therapy staff completed an assessment, which said Mrs D could stand independently and walk 7 metres with her hand held. Her confidence was decreased. She had a stair lift at home. The therapist asked that Mrs D have two daily care visits. These would be 45 minutes from 7am to help with washing, dressing and breakfast, then 30 minutes at 12:15 to help with lunch, provide a drink, and prepare her tea for the evening.
  8. On 5 October, hospital staff recorded that Mrs D could stand, move around, and manage her personal care tasks independently. She felt safer using a walking frame. She agreed to a referral to the community physiotherapist to progress with her mobility and increase her confidence. Therapy staff decided she could safely go home with support with meals and drinks from carers and Ms F. They made the referral for the care visits, to start at 12:15pm the following day.
  9. In the morning of 6 October, Ms F collected Mrs D from hospital. A support worker arrived at her home. There is conflicting information about the time they arrived. The support worker’s notes say 1:30pm, Mr P says it was much later than 1:30pm, and notes made by another member of social care staff on 11 October say the support worker arrived at 2:15pm after an emergency with another person. The support worker recorded that they helped Mrs D to dress, then asked her to try walking to the stair lift with her frame. Mrs D managed only 6-8 steps and was exhausted, so the support worker got her back to her chair. The support worker’s notes say no one had given Mrs D a commode, and she needed to be able to get upstairs to use the toilet. The support worker went upstairs, and found another walking frame there. However, it would not fit through the door into the bedroom because of the position of furniture. The bed had no lever, and Mrs D said she could not lift her legs into bed by herself. Ms F was very upset about not being consulted at all about the discharge. Ms F and Mrs D agreed that they would try to arrange for Mrs D to go to a care home for two weeks.
  10. The Council completed a support plan for Mrs D on 11 October. It said because Mrs D was weak following her illness, she needed support with her personal care tasks. Mrs D’s home was not suitable because all the facilities were upstairs. Therefore, Mrs D needed an emergency residential placement so she did not have to go back into hospital.
  11. The support plan says Mrs D was not moving around the care home much because of fatigue. She could struggle to stand from her chair. She needed supervision when moving around because she was at high risk of falls. She needed assistance to use the toilet. Often, she appeared to fall asleep, so she could not be left to do tasks alone. She also said she often felt “fuzzy”, which affected her ability to move around. She could not lift her legs to get in bed by herself. The support plan also notes that the assessment completed in hospital incorrectly said Ms F lived with Mrs D. Ms F had only stayed with Mrs D for a few days. The member of staff noted that though Mrs D had full capacity to make decisions, she was very tired, and fell asleep several times during the conversation. She needed 24 hour care to keep her safe.

Complaints process

  1. Mr P complained to the Trust about these events. He said hospital staff should not have accepted Mrs D’s statement that she did not need help and that her daughter would be staying with her. He said the family told the ward “constantly” that this was not the case. He said staff should not have accepted the assurances of a 90 year old woman recovering from pneumonia, they should have checked. Mrs D was still in a care home, two months after discharge, and both the care home manager and the Council’s staff had told him the discharge was unsafe. He said if the hospital had not changed its mind about Mrs D going to rehabilitation before going home, Mrs D would not have had to suffer the anxiety she did.
  2. The Trust wrote to Mr D on 14 November. It said it was sorry if the family were told there would be a case conference about Mrs D’s discharge then this did not happen. It said it initially thought Mrs D would need rehabilitation to improve her confidence, but when she was reviewed it seemed she no longer needed this. It said an occupational therapist reviewed whether Mrs D would need any equipment before she went home.
  3. The Council wrote to Mr P on 19 January 2018. It said it was not involved in decisions about the level of support or equipment Mrs D needed after discharge, and Mr P should contact the Trust.
  4. Mr P complained to the Council again on 9 February. He said the assessment said Mrs D should have a morning and lunchtime care call but this was not put in place. He said Ms F called because no one arrived, then the support worker came. He said Mrs D should have had a home visit to check her needs before she was discharged. Mrs D was very distressed at home, and could not use the toilet for four hours.
  5. The Trust wrote to Mr P again on 16 February. It said it got information about Mrs D’s home situation when it did the assessment. It said because her level of independence improved, she no longer met the criteria for rehabilitation and agreed to go home with care. It said she had the capacity to make this decision, and said her daughter could support her in the evenings. Staff were confident that they could discharge her safely at the time.
  6. The Council responded again on 21 March. It said it was not involved with Mrs D’s discharge, the hospital did this. It said when the support worker visited at 1:30pm on the day of Mrs D’s discharge, “it was plain to [the support worker] that [Mrs D] should not have been discharged home”. The Council said the care package the hospital arranged was not enough for her, and Mrs D did not have equipment she needed at home.
  7. Mr P complained to the Trust again on 11 April. He said the Council’s response said it was clear Mrs D should not have been discharged, so he questioned the Trust’s assertion that she could be discharged safely. He said the Trust’s PALS office told the family at 13:20 on 6 October that no care package had been arranged, and he would tell the appropriate team. He assumed this prompted the visit from the support worker.
  8. The Trust responded again on 4 May. It said it was agreed based on assessments, observations and discussions that Mrs D was fit for discharge. Staff referred Mrs D for a care package, and were told this was in place in time for her discharge.
  9. On 16 May, Mr P spoke with the Trust’s Matron, who apologised that there had been some miscommunication and the family were not as involved with the discharge as they could have been. The Trust’s complaints staff explained to Mr P that they had discussed his complaint with senior clinicians and reiterated the importance of listening to the people who know the patient best.


  1. There is no evidence that the hospital staff consulted with Mrs D’s family about the discharge, as they should have done. Mr P says they told the nurses that Ms F was not living with Mrs D. The nurses did not document this in the records, so the information was not available to the staff who planned her discharge. Lack of communication with the family is a particular concern given the decline in Mrs D’s confidence, and her stated concerns about how she would manage at home. The Trust was at fault here.
  2. Had staff consulted the family, they would have known that Ms F could not care for Mrs D in the evenings, so the planned care package was not sufficient. It is not a requirement for staff to visit a patient’s home before discharge to check it. But discussing discharge plans with Mrs D’s family would have created an opportunity to discover that Mrs D could not use her walking frame upstairs, and to discuss arranging for her to live downstairs at her home. They could also have discussed whether she wanted or needed assistance to move the commode inside from the garage.
  3. I have concerns about the ward sister telling the therapy staff that Mrs D could not go to a rehabilitation placement because her mobility was too good. Mobility is not the only factor when considering whether someone needs a rehabilitation placement. Psychological factors are also relevant. There is evidence that Mrs D lacked confidence in her abilities. She had a history of falls, and had fallen on the ward. A rehabilitation placement could have worked with her on building her confidence. There is no evidence that she was referred to a rehabilitation placement but the referral was declined. The Trust should have continued with its plan to look for a rehabilitation placement for her.
  4. If the Trust had discussed discharge plans with Mrs D’s family, and further pursued its plan to refer her to a rehabilitation, then her anxiety when she was discharged home and the need to urgently find a respite placement for her could have been avoided. This was an injustice to the family.
  5. However, it should be noted that the Trust’s therapy staff had comprehensively assessed Mrs D’s abilities before she was discharged, and in hospital she was significantly more able than she was when she went home. Therefore, I have not found that Mrs D should not have been discharged from hospital at all.
  6. Mr P said a PALS officer indicated to him that Mrs D’s care package had not been set up. I cannot account for this, but the evidence suggests that it had been set up. The Council’s records say the support worker was late for the first planned visit because they were held up at an earlier visit to someone else.
  7. So, I find that the Trust was at fault for not discussing plans for Mrs D’s discharge with her family and for not continuing with its plan to refer her to a rehabilitation placement. I find that because of this, Mrs D and her family suffered unnecessary distress. I do not find that the Council failed to set up a care package.
  8. In my draft decision, I proposed to find fault with the Trust and Council for not jointly investigating and responding to Mr P’s complaint. The Trust and the Council both disputed this. Their reasons included that Mr P’s correspondence to each initially contained concerns which were specific to each organisation, and that Mr P told both organisations he was liaising separately with the other so they understood he did not want a joint response. On balance, therefore, I have decided not to find fault with them for not investigating the complaint jointly.

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Agreed action

  1. Within two months of this decision the Trust will write to Mr P and Mrs D to apologise for the distress caused by the fault with the discharge planning. It will also explain what action it has taken to prevent similar faults with discharge planning happening again, and how it will monitor the effectiveness of this. It will copy this letter to the Ombudsmen. It will also send a copy of its letter and this decision statement to the Care Quality Commission and NHS Improvement, without any details identifying Mrs D or Mr P.

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  1. I find that there was fault with the Trust’s discharge planning. This caused distress to Mrs D and her family, which is an injustice.
  2. I consider that the action the Trust has agreed to take will satisfactorily remedy the injustice. Therefore, I have completed my investigation.

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Parts of the complaint that I did not investigate

  1. I did not investigate part c of the complaint, about the cost of the first 6 weeks of Mrs D’s care. This matter was resolved after the complaint was brought to the Ombudsmen, because the Council agreed to waive these charges.

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Investigator's decision on behalf of the Ombudsman

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