Summary: The Ombudsmen found no fault with West Midlands Ambulance Service NHS Foundation Trust’s decision not to send Mr X to hospital, or how it classified a call from Mr X’s GP. The Ombudsmen consider University Hospitals Coventry & Warwickshire NHS Trust shared appropriate information with a care home before it discharged Mr X. Also, the Ombudsmen found no fault with how Coventry City Council assessed Mr X’s care and support needs.

The complaint

1. Mrs X complains about the care provided to her husband, Mr X, by Coventry City Council (the Council), West Midlands Ambulance Service NHS Foundation Trust (the Ambulance Trust) and University Hospitals Coventry & Warwickshire NHS Trust (the Hospital Trust) in late 2017 and early 2018. Specifically, she complains:
• The Ambulance Trust failed to take Mr X to hospital on 25 November 2017;
• The Ambulance Trust classified a referral from Mr X’s GP on 27 November 2017 as an ‘urgent’ rather than ‘emergency’ call;
• The Hospital Trust did not share information with a care home before it discharged him in January 2018;
• The Council and Hospital Trust wrongly decided Mr X could go home from the care home, but it was not safe because she could not care for him; and
• A Council social worker did not listen to Mrs X’s above concerns.
2. Mrs X says:
• The Ambulance Trust’s decision on 25 November 2017 led to delayed treatment for Mr X’s bleed on the brain;
• The Hospital Trust’s failure to give the care home information about Mr X meant the care home could not prepare for Mr X; and
• The Council and Hospital Trust’s actions caused her significant stress when she already unwell.
3. Mrs X would like the Council, Ambulance Trust and Hospital Trust to recognise and apologise for the mistakes. She would also like them to act to prevent similar issues reoccurring, including staff training.

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The Ombudsmen’s role and powers

4. 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).
5. 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.
6. The Ombudsmen can require anyone to provide information or documents relevant to an investigation. (Section 12(1) of the Health Service Commissioners Act 1993 and section 29(1) of the Local Government Act 1974)
7. 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))
8. The Ombudsmen may investigate, and question the merits of, action taken in the exercise of clinical judgement.
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. I considered information Mrs X provided in writing and by telephone. I asked the Council, Ambulance Trust and Hospital Trust to comment on the complaint and provide supporting documentation. I have taken the relevant law and guidance into account. I also sought independent clinical advice from a paramedic.
11. I have written to Mrs X, the Council, the Ambulance Trust and the Hospital Trust with my draft decision and considered their comments.

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What I found

Key facts

12. On 25 November 2017, Mrs X called 999 and asked for an ambulance for Mr X. He had slurred speech, difficulty breathing, and had fallen the day before. After assessing Mr X, the paramedics decided not to admit Mr X to the Hospital Trust.
13. Two days later, Mr X’s GP made an urgent referral to the Ambulance Trust at 4.45pm. Mrs X called 999 at 7.23pm to chase the ambulance, and the ambulance arrived at 8.11pm. After assessing Mr X, the paramedics decided Mr X needed further assessment at the Hospital Trust.
14. The Hospital Trust later found Mr X suffered a bleed on the brain from the fall. While his prognosis was poor, Mr X’s condition improved during the admission. In December 2017, the local clinical commissioning group (the CCG) asked a care home to assess Mr X, as he was clinically fit for discharge. However, he most likely needed further support from health and social care services. The CCG agreed to fund the placement.
15. On 29 December 2017, the manager of a care home completed her assessment of Mr X, and he moved there on 4 January 2018. After a few extensions, the placement (funded by the CCG) would end on 5 May.
16. In February 2018, the Council assigned a social worker to Mr X to assess his social care needs. The social worker met Mr and Mrs X on 8 March. The social worker said Mr X did not meet the criteria for support in a residential placement. Mrs X said she could not support her husband at home, as she was waiting for a hip operation and could not support him. The social worker asked an occupational therapist to visit their home, which happened on 14 March.
17. During a discharge planning meeting at the care home (on 6 April 2018), the social worker and occupational therapist said Mr X could return home with support. If there were any issues, the social worker agreed to review the Council’s package of care. The care home manager and a physiotherapist also agreed he could return home as he had made good progress at the care home. Mr X said he wished to return home. Mrs X said she felt no one was listening to her. She was worried how he would cope at home when she was not there.
18. The social worker later agreed to help Mr and Mrs X find a residential placement they could pay for privately. Mr X moved to a residential home on 5 May.

Complaint responses

19. In February 2018, the Ambulance Trust said the paramedics’ management of Mr X on 25 November 2017 was appropriate. Also, it sent an ambulance within four hours of the GP’s request on 27 November.
20. Also, in February 2018, the Hospital Trust said it made a detailed referral to the care home. There were several phone calls with the care home, and the care home manager completed her assessment of Mr X at the hospital on 29 December 2017. The Hospital Trust apologised it did not share information with Mrs X.
21. In April 2018, the Council said:
• Its social worker and an occupational therapist felt Mr X could manage at home with a package of care;
• Mr X had capacity to decide to receive support at home if he wished;
• It appreciated Mr X preferred to self-fund at a residential home until Mrs X was ready for him to return home; and
• It would reassess Mr X if his condition changed and needed different support.
22. The Council provided another response to Mrs X in June 2018. It said the social worker denied suggesting Mrs X lock her husband in the house, if she needed to go out. The social worker also considered Mrs X concerns as Mr X’s carer.

Analysis

The Ambulance Trust’s decision on 25 November 2017

23. The clinical records are robust and show the Ambulance Trust completed the right assessments considering Mr X’s condition. This included assessments of his chest and heart. The crew also took Mr X’s blood pressure and explored if his condition was due to a urinary infection.
24. There clinical records suggest Mr X was mobile (he had his blood pressure recorded as ‘standing’). He was also receiving support from the falls team. The paramedics also noted his clinical observations were within the normal limits.
25. Overall, I do not consider the Ambulance Trust should have sent Mr X to the Hospital Trust on 25 November 2017. The paramedics provided good clinical care and treatment to Mr X.
26. In the clinical records, the paramedics noted it provided Mrs X with advice on what to do if she spotted “red flags” with Mr X. The paramedics should have detailed what those “red flags” were in the notes. However, I am satisfied this was not fault.
27. Mrs X said that soon after the Hospital Trust admitted Mr X, a consultant told her the paramedics should have sent her husband to hospital on 25 November 2017. I do not doubt Mrs X’s version of events. However, I have not seen any other corroborating evidence from the time of the event, that a consultant said the paramedics should have admitted her husband on 25 November.

The urgent call classification on 27 November 2017

28. The Ambulance Trust’s 2016 ‘EOC Dispatch Protocols’ state the Ambulance Trust is responsible for ensuring patients reach their destination within two (emergency) or four (urgent) hours. However, it is not responsible for deciding if a patient is considered an emergency or urgent case. This would be for the person making the referral to decide.
29. I do not consider the Ambulance Trust was responsible for classifying the call as urgent rather than emergency. This was the responsibility of Mr X’s GP. As I am not investigating Mr X’s GP, I cannot say the Ambulance Trust was at fault.
30. After Mrs X’s follow up 999 call, the ambulance arrived within four hours of the GP’s referral. Therefore, I do not consider the ambulance took too long to respond to the GP’s urgent call.

The Hospital Trust’s provision of information to the care home before it discharged Mr X

31. Mrs X said the care home manager had to take notes from the reception to complete her assessment of Mr X. No staff discussed Mr X with the care home manager before discharge. Also, Mrs X said that her husband was admitted to the care home, staff did not know he suffered a bleed on the brain or even why he was in the care home.
32. I spoke to the care home manager during my investigation. She said she spoke to Hospital Trust staff and Mr X during her assessment on 29 December 2017. She considered his medical notes. She also said care home staff were aware of Mr X’s condition and why he was there because it was in his notes, which staff could see.
33. The Trust told me it worked with the care home manager to help her complete the assessment. I have seen evidence the care home manager wrote her notes into Mr X’s Hospital Trust clinical records. Also, the care home manager’s assessment had Mr X’s medical history, medication list and his detailed needs.
34. When the Hospital Trust discharged Mr X, it sent the care home a copy of the discharge and nursing transfer letter. Also, I have seen evidence the Hospital Trust followed up with the care home to ensure it received all the equipment Mr X needed.
35. Overall, I consider the Hospital Trust provided appropriate information to the care home before and when it discharged Mr X.

The Council’s assessment of Mr X

36. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment of any adult who appears to need care and support. They must assess anyone, regardless of their finances or whether the council thinks they have eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the outcomes they want to achieve. It must involve the individual and where appropriate their carer or any other person they might want to be involved.
37. An assessment should be carried out over an appropriate and reasonable timescale considering the urgency of needs and a consideration of any fluctuation in those needs. Councils should let the individual know of the proposed timescale for when their assessment will be conducted and keep the person informed throughout the assessment process.
38. The Council is responsible for completing assessments of service users’ needs and deciding what support they should receive. I cannot decide what level of social care was appropriate for Mr X. Rather, I have looked at the way the Council made its decisions.
39. The social worker said the Council could meet Mr X’s needs at home, with a package of care. I consider the social worker appropriately included an occupational therapist, physiotherapist, care home manager and Mr and Mrs X before deciding what support was necessary. All, except for Mrs X, agreed Mr X could manage at home with a package of care. The social worker robustly considered Mr X’s needs for support, which reduced at the care home.
40. I have seen evidence in the social care records that the social worker considered Mrs X’s view she could not cope with her husband at home. She mentioned it many times between March and May 2018. I see the social worker tried to explain Mrs X did not have to provide personal care to her husband at home. This was in line with the Care Act 2014 guidance. I do not consider there was fault in how the social worker assessed what support the Council would provide for Mr X.

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Final decision

41. The Ambulance Trust provided good clinical care and treatment to Mr X. The paramedics correctly decided Mr X did not need to go to hospital.
42. The Ambulance Trust was not responsible for classifying the request for an ambulance as ‘urgent’ rather than ‘emergency’ on 27 November 2017. Also, an ambulance arrived within four hours of the GP’s request.
43. I consider the Hospital Trust provided appropriate information to the care home before and when it discharged Mr X.
44. I have not found any fault with the way the Council decided what support Mr X needed.

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Investigator's decision on behalf of the Ombudsman