Summary: Mr G complains about the treatment of his mother by a Trust and Council relating to her hospital discharge in July 2017. The Ombudsmen do not uphold the complaint against the Trust as they found no fault in its actions. They found fault with the Council in relation to communication with the family. However, the Council has now provided a suitable response.

The complaint

1. Mr G complains about East Cheshire NHS Trust (the Trust) and Cheshire East Council (the Council) regarding issues surrounding his mother, Mrs H’s hospital stay and discharge in 2017. Specifically Mr G complains:
2. The Trust

• Did not have a neurologist review his mother until three weeks after her admission
• Did not include important consultants’ letters in his mother’s medical records
• Discharged his mother from hospital in July 2017 against the advice of a consultant neurologist (the Consultant Neurologist) who was treating her

3. Mr G also complains the Council:

• Told him the Consultant Neurologist supported the decision to discharge when this was not the case; and
• Reduced his mother’s domiciliary care package at the last minute without discussing the change with the family.

4. Mr G says the discharge was unsafe and resulted in a decline in her physical health and cognitive function. He said this led to her readmission within 48 hours of discharge. Mr G says this caused significant distress for his mother and the family in general.
5. Mr G would like explanations from the Trust and Council for why the above failings occurred.
6. Mr G wants the Trust and Council to acknowledge the discharge was unsafe and apologise for this. He would also like the Trust and Council to explain what they will do to prevent similar problems occurring in future.

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The Ombudsmen’s role and powers

7. 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)
8. 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).
9. 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

10. During the course of my investigation I have considered the following evidence:
• Telephone conversations, emails and papers provided by Mr G relating to his complaint
• Evidence from the Trust including the complaint file and Mrs H’s medical records
• Evidence from Council including the complaint file and Mrs H’s social care records
• Independent clinical advice from a Consultant Physician (our Adviser) with relevant experience in similar cases
• Mental Capacity Act 2005 (MCA)
• Ready to Go? - Planning the discharge and the transfer of patient form hospital and intermediate care (2010)
• I took into account of Mr G’s comments on my draft decision before making this final decision. The organisations did not make any comments.

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What I found

Legal background

11. The MCA is designed to protect and empower people who may lack the mental capacity to make their own decisions about their care and treatment. The MCA says:

• assume a person has the capacity to make a decision themselves, unless it's proved otherwise
• wherever possible, help people to make their own decisions
• don't treat a person as lacking the capacity to make a decision just because they make an unwise decision
• if you make a decision for someone who doesn't have capacity, it must be in their best interests
• treatment and care provided to someone who lacks capacity should be the least restrictive of their basic rights and freedoms

Background

12. Mrs H was suffering from a brain tumour and had undergone an operation in to reduce the size of the tumour. She also underwent chemotherapy and radiotherapy. Following the therapy, she suffered from confusion and mobility issues. She was admitted to Wythenshawe Hospital on 29 May 2017 after a fall. She was transferred to Macclesfield District General Hospital which is operated by the Trust, in July 2017. Mrs H left hospital on 27 July with a package of care but within 48 hours she suffered further falls and had to be readmitted.
13. Mr G complained to the Trust about the treatment and the care package. The Trust involved the Council in providing a response to Mr G and he then approached the Ombudsmen in February 2018.

The Trust

Did not have a neurologist review his mother until three weeks after her admission

14. Mr G said despite seeing numerous other doctors, his mother did not see a neurologist until 25 July, over three weeks after her admission to Macclesfield District General Hospital and only after his sister requested a meeting with a doctor to discuss Mrs H’s situation
15. The Trust has not responded to this complaint. However, it is the case Mrs H saw the Consultant Neurologist on 25 July.

Analysis

16. From reviewing the evidence in the records and clinical advice, it is correct that Mrs H did not see a neurologist during the first three weeks of her stay in hospital. However, following a brain tumour, patients would normally see a neurosurgeon rather than a neurologist. They would usually be managed by an oncologist or a neurosurgeon. In addition, after the operation, Mrs H’s various health issues were dealt with by the appropriate specialists including a physician, physiotherapist, and occupational therapist.
17. The only issue that could have required neurological input were her history of a seizure but these can often be looked after by a non-specialist, including nurses.
18. Taking this into account, although it was the case that Mrs H did not see a neurologist for three weeks, this was not fault by the Trust and she was seen by the right type of specialists during her stay.

The Trust did not include important consultants’ letters in his mother’s medical records

19. Mr G complained that vital information from consultants’ letters was not included in his mother’s set of medical notes. Mrs H attended an oncology consultation on 5 July 2017 at the Christie Hospital. The consultation letter detailed concerns about Mrs H’s ability to cope at home. Mr G’s sister became concerned that by 21 July the letter was still not included in her mother’s notes. She contacted the Christie and it confirmed the letter was faxed to Macclesfield Hospital on 6 July and was shared with Mrs H’s GP and Social Worker. The Christie asked the Social Worker to bring the letter to the ward on 21 July. The family complained about this and said it was also a concern for other patients that letters were not being added to their notes.
20. The Trust confirmed that an MRI referral requested by the 6 July letter was made on 7 July which confirmed that the letter did arrive at the hospital. However, it was unclear why it had not been added to the notes. In addition the Trust said it was with regret it could not confirm when exactly the letter was added to the records.

Analysis

21. Although the letter in question is in the copy of the records the Trust gave the Ombudsmen, I have also not been able to confirm when the letter was added to the records. However, I am satisfied the MRI referral was made and I have not found any detriment to Mrs H’s care as a result of any lapse. Therefore, I do not consider it would be proportionate to pursue this element of the complaint further.

The Trust discharged Mrs H from hospital in July 2017 against the advice of a consultant neurologist who was treating her

22. Mr G said on 25 July Mrs H and family members met with the Consultant Neurologist and it was agreed Mrs H was to have a medication change and that she would not be safe to leave the hospital. Mr G said the next day Mrs H phoned her daughter in a panic because she had been told she was to be leaving hospital and she did not understand what was going on.
23. Mr G said all of Mrs H’s consultants (her neurosurgeon, oncologist and neurologist) described her mental state as variable and intermittent and described how it is difficult to assess capacity in such cases. Due to these issues, when asked if she wanted to go home, Mrs H would say yes as she believed she was capable of returning to her pre-illness independent life.
24. Mr G said during July and August, his mother saw a number of consultants. All were concerned by the deterioration in her condition. With this volume of medical evidence Mr G said he found it hard to understand how his mother was deemed fit to return home with minimal support.
25. Mr G said his mother left hospital on 27 July but unfortunately, as predicted by the family and the Consultant Neurologist, she was unable to cope even with four daily care visits and was readmitted via A&E on 29 July. Mr G went on to say during the 48 hours his mother was at home she had a number of falls, had to use her pendant alarm and made several distressing calls to family members as she became very confused about where she was and what to do.
26. Mr G also pointed to a letter of 2 August from the Consultant Neurologist, wrote: “The patient also appears to have a neuro behavioural frontal syndrome with impulsive acts/poor decision making which has led to falls. This is compounded by associated pyramidal weakness and associated unsteadiness……I expressed my concerns in the notes of discharging at a time when she was not properly mobile...”
27. The Trust said that the doctor who made the decision to discharge Mrs H from hospital took on board the Consultant Neurologist’s reservations but felt that Mrs H was medically fit for to leave hospital and she had expressed a wish to go home. The Trust also said an assessment of Mrs H’s mental capacity confirmed she had insight into the challenges of returning home, how to handle these and she was not confused.

Analysis

28. Patients such as Mrs H can be assessed and a care plan put in place whilst in hospital. However, they would not be required to stay there if deemed medically fit. Mrs H was seen by a team with the appropriate range of specialities. She was classed as medically fit to leave hospital, with a care package of support at home. In addition, two separate people assessed her capacity, and under the requirements of the Mental Capacity Act (MCA) she could make decisions. If a person in these circumstances wants to go home then they should do so with an appropriate care package where necessary.
29. Decisions about a person’s mental capacity exist for a specific decision taken at a specific time. It is noted that sometimes her ability to make a decision may have been compromised, however this did not invalidate her ability and right to make decisions about herself at times when she does have capacity.
30. The Consultant Neurologist could contribute but ultimately it was a decision for the team in charge of her care to make. This team balanced the evidence correctly in coming to the decision Mrs H was fit to leave hospital with a care plan in place.
31. Notwithstanding the issues Mrs H unfortunately suffered following her return home, after considering all the evidence I do not find it was fault by the Trust in discharging Mrs H from hospital.

The Council

The Council told Mr G the Consultant Neurologist supported the decision to discharge Mrs H from hospital when this was not the case

32. Mr G said his sister met the Consultant Neurologist on the ward on 1 August following Mrs H’s readmission. Mr G said in this conversation the Consultant Neurologist confirmed he had not agreed to for Mrs H to leave hospital as he felt she would be unsafe. The Consultant Neurologist then rang the Social Worker from the ward and asked her if she had told the family that he was happy with the decision. Mr G said the Social Worker replied that she had not told the family this. However, Mr G pointed out an email of 27 July in which the Social Worker stated the Consultant Neurologist was happy with the decision, providing Mrs H had medication support.
33. The Council told the Ombudsmen the Social Worker’s email of 27 July to Mr G does state the Consultant Neurologist said Mrs H was safe to leave hospital as long as she had support.
34. However the Council said the Social Worker’s case notes for 25 July record the conversation with the Consultant Neurologist. The notes state he would be concerned about Mrs H returning home with no support. The notes say he was then told that she was going home with reablement, telecare and support rails. The notes further record that he was happy with that but did not know Mrs H enough to say whether she was safe to return home and felt that this was a matter for the team arranging her discharge from hospital.
35. The Social Worker has said this was her understanding of the Consultant Neurologist’s position. The Council apologised for any distress caused by any misleading information relayed to the family.
36. Furthermore, the Council reminded the Social Worker of the need to ensure that all communication with families to be an accurate reflection of third party conversations.

Analysis

37. From looking at the evidence, the Council’s version of events is backed up by the Social Worker’s case notes taken in July 2017. The Social Worker was at fault in telling the family the Consultant Neurologist supported the decision to discharge Mrs H from hospital without properly outlining the conversation she had with him. This caused a misunderstanding between the family, the Social Worker and Consultant Neurologist. The Council has reminded the Social Worker of effective communication in the future and this is reasonable in the circumstances.

The Council reduced his mother’s domiciliary care package at the last minute without discussing the change with the family

38. Mr G said that the family had been informed that his mother would be discharged from hospital with four daily home visits from carers. However, at the last minute the care package was reduced to just three visits.
39. The Council told the Ombudsmen it informed the family by email on 25 July of the planned support of four calls a day from the reablement service. However, it later transpired on the day (27 July) that due to a lack of resource, the reablement service was only able to offer three calls a day. The Social Worker said she discussed this change to the proposed reablement plan with Mrs H who accepted the changes and the associated risks and was keen to return home. She went on to say she then rang Mrs H’s daughter in law to advise her of the change.
40. The Council admitted the Social Worker did not document either of these conversations. It went on to say it had reminded her of the importance of documenting all relevant conversations.
41. The Council said while the Senior Care Support Worker was completing the first assessment with Mrs H and her daughter on the day, her daughter raised concerns about only three calls being available.
42. The Senior Care Support Worker contacted her manager and confirmed the service could provide an additional call and Mrs H was provided with four calls as originally planned.

Analysis

43. Having considered all the evidence I found the family were caused distress by being not being informed earlier that that their mother’s care package would not be the four visits originally planned. However this was swiftly remedied at the time and I would not recommend any further action following the Council’s reminder to improve record keeping.

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Final decision

44. I have not found fault with the Trust’s actions and the Council has explained the communication errors relating to the decision to discharge Mrs H from hospital and care plan.

Investigator’s final decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman